Client Intake Form

Name:

Spouse’s Name:

Social Security #:

Social Security #:

Date of birth:

Date of birth:

US Citizen:  Yes   No   (Circle one)

US Citizen:  Yes   No   (Circle one)

Occupation: 

Occupation: 

Are you legally blind or

totally and permanently disabled?  Yes     No

Are you legally blind or

totally and permanently disabled?  Yes     No

 

Address: ________________________  City:  ____________________  State:  ______  Zip: _________

 

Phone:  ________________________  Alternate phone:  ______________________

 

Email:  ____________________________

 

Do you expect any significant changes in your income from last year or for next year? __________

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Marital Status:  As of December 31st, 2014, you were:

 

Single _____

 

Married _______ Did you live with your spouse any part of the last 6 months of the year?

 

Divorced or legally separated ________ 

            Date of final divorce decree or separate maintenance agreement:  ______________

 

Widowed __________ 

Date of spouse’s death:  ______________

 

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List the names of everyone you supported during the year, even if they did not live with you.  Do not list yourself or your spouse.

 

Name

Date of birth

Relationship

# of months lived in your home

US citizen or resident of US, Canada, or Mexico

Single as of end of year?

Full time student?

Received more than $3650 in income?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

In addition to the items listed under “What to have ready for your tax lady”, do you have any of the following situations?

 

  • Tip income
  • Scholarships
  • Self-employment income or loss, such as from earnings from contract labor (Form 1099 Misc) or small business (Schedule C).
  • Sold stocks, bonds, mutual funds; either gain or loss
  • Rental property
  • Made contributions to a retirement account such as IRA, or 401k
  • Earned income credit was disallowed in a previous year
  • Live in an area that was affected by a natural disaster
  • Receive the First Time Homebuyer’s Credit in previous years

 

 

 

 

 

 

 

 

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Please fill out, print, and have available for your "tax lady."
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