Tax Intake Form

TAXPAYER

* Required Fields
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SPOUSE

FILING STATUS

ADDRESS

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DEPENDENTS

AFFORDABLE CARE ACT

(If not covered for all 12 months, Please provide Form 1095-A & complete Affordable Care Detail Intake Form.)

REFUND TYPE


(In about 7-14 days from the date your return is accepted electronically by the IRS, you receive a check for the amount your refund less filing fees. (Check will be available in our office))

(In about 7-14 days from the date your refund is accepted electronically by the IRS, for the amount your refund less filing fees will be deposited onto the debit card we issued you.)

(In about 7-14 days from the date your refund is accepted electronically by the IRS, for the amount your refund less filing fees will be deposited into your bank account.)


(Your refund will be deposited into your savings or checking account directly from IRS approximately 10-14 days after your return is accepted by IRS.)

(Your refund will be mailed to you directly from IRS in approximately 3-4- weeks after your return is accepted electronically by the IRS.)

(Your refund will be mailed to you directly from IRS in approximately 6-8- weeks after your mail your return to the IRS.)

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Tax Client Photo ID and Voided Check – Required!

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Due Diligence Questionnaire

(* Required if you selected you selected 'Yes' in 'Are any of the Dependents being claimed NOT your Son or Daughter?'.)

Schedule – C – Form

Fill out COMPLETLEY or mark “N/A”. DO NOT leave blank. Use a separate worksheet for EACH SCH - C **Please Note: If possible, it is preferred a trial balance, P&L and balance sheet be provided by the client. If available, write “see next page” below and stuck under this page. If NOT AVAILABLE, Please use the input sheet below.

Business Info: (Required for all)
Income Questions: (Required if no P&L or Trial Balance Available)
General Expenses: (Required if no P&L or Trial Balance Available)
Expenses
Value (IN $)
Expenses
Value (IN $)
Advertising:
Repair & Maintenance:
Auto Expense:
Supplies:
Commissions:
Taxes & Licenses:
Contract Labor
Travel:
Depletion
Meals (Total):
Employee Benefit Program:
Utilities:
Insurance (other than health):
others:
Interest
a. Mortgage:
b. Other:
Legal & Professional:
Office Expense:
Pension & Profit Sharing:
Rent or Lease:
a. Vehicles:
b. Machinery
c. Other:
Total Expenses:
Net Income: Total Income – Total Expenses =
(Please attach any other supporting document(s) if available)

By signing above, I hereby certify the information given above is true and accurate.

Income Summary

MONTH
SERVICE
$ MADE
January
February
March
April
May
June
July
August
September
October
November
December

Total

Dependent Care Form

STANDARD DEPENDANTS
1
2
3
4
NON STANDARD DEPENDENTS (Grandchild, niece, nephew, stepchild, foster child, etc.):
ADULT DEPENDANTS

By signing above, I hereby certify the information given above is true and accurate to the best of my knowledge.

Student Acknowledgment Form

I, was a student during the school year, and attended . I certify that all of the information found on this form is true and to the best of my knowledge. I understand it is my responsibility to have all valid documents and or receipts, as required to apply for any type of school credit. Below is a recap of all information, status, and expenses I have encountered.
My scholar status:
Below are my total educational expenses:
IN ($)
Books:
Supplies (On campus):
Supplies (Off campus):
Other expenses:
Total:
By signing below I certify all information is true, valid, and to the best of my knowledge. I accept full responsibility of the statements mentioned above. Any and all disputes regarding this matter shall be forwarded to me with the information found on my tax returns forms.

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Schedule - A – Information

MEDICAL EXPENSES
CURRENT YEAR (IN $)
Medical & Dental Expenses
Medical Insurance Premiums Paid (Other than Social Security Medicare Payments)
Long Term care Premiums
Prescription Drugs & Medications
Medical Miles Driven
TAX EXPENSES
CURRENT YEAR (IN $)
State & Local Income Taxes Paid (Other than those on W-2’s, 1099’s, etc.)
Income Taxes paid
Real Estate Taxes
Personal Property Taxes
Other taxes:
Qualified New Vehicle Taxes
Additional State/ Local Taxes
INTEREST EXPENSE
CURRENT YEAR (IN $)
Home Mortgage Interest reported on Form 1098
Home Mortgage Interest paid to others
Refinancing Points Paid i
Investment Interest (other than K-1)
CONTRIBUTIONS
CURRENT YEAR (IN $)
Cash Contributions (If over $500 please provide detailed list)
Non Cash Contributions (If over $500 please provide detailed list)
Volunteer Mileage Driven
Miscellaneous
CURRENT YEAR (IN $)
Unreimbursed Business Expenses
Union Dues
Tax Prep Fees (Paid for Previous Return)
Safe Deposit Rental
Other Expenses:
Investment Expenses (Other than K-1)
Gambling Losses (Due to extent of winnings)
CASUALTY & THEFT LOSSES

If you had any casualty or theft losses during the year, please provide detail below, including date, description, amount of casualty or loss, any insurance reimbursement & basis in the property.


Affordable Care Details:

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
TAXPAYER:
Insured through Marketplace
Coverage from other source
Exempt from Mandate
SPOUSE:
Insured through Marketplace
Coverage from other source
Exempt from Mandate
DEPENDENT 1
Insured through Marketplace
Coverage from other source
Exempt from Mandate

REQUIRED TO FILE A RETURN?

YES
NO
DEPENDENT 2
Insured through Marketplace
Coverage from other source
Exempt from Mandate

REQUIRED TO FILE A RETURN?

YES
NO
DEPENDENT 3
Insured through Marketplace
Coverage from other source
Exempt from Mandate

REQUIRED TO FILE A RETURN?

YES
NO

If employer sponsored health coverage was declined:

TAXPAYER: SPOUSE:
What would cost of SELF coverage have been $ $
What would cost of FAMILY coverage have been? $ $
Would FAMILY policy have covered spouse? YES
NO

OTHER CALCULATION QUESTIONS

Did you pay for health coverage for anyone not on your return? YES
NO
Did anyone else pay for health coverage for someone on your return? YES
NO