Individual Intake Form

Subject *

Your Email *

First Name *

Last Name *

Social Security# *

Occupation

Date of Birth *

Cell Phone# *

Home Phone#

Home Address#

Marital Status *

SingleQualifying Surviving SpouseHead of HouseholdMarried Filing Jointly

Active Military Duty? *

YesNo

Are you legally blind? *

YesNo

Banking

Bank Name

Account Number

Child care & education

Qualifying Child Care expense incurred and paid

Please identify child associated with dependent care expense

Education Expense Paid

Please identify child associated with education expense

Charitable contributions

#1 Entity Name

#1 Amount

#2 Entity Name

#2 Amount

#3 Entity Name

#3 Amount

Housing

Do you own or rent? *

OwnRent

For Homeowners, please provide appropriate documentation - including Form(s) 1098Max 8 MB per file.

Did you file Sch. C last year? *

YesNo

Please provide copy of last years Sch. C.Max 8 MB per file.

Landlords Name

Landlords Address

Annual Rent Paid

Spouse information

Spouse First Name

Spouse Last Name

Spouse Social Security#

Spouse Occupation

Spouse Date of Birth

Spouse Cell Phone#

Spouse Home Phone#

Spouse Email

1. Dependent/s Information

Dependent First Name

Dependent Last name

Dependent Social Security#

Dependent Relation

Dependent Date of Birth

Dependent Months in Home

Dependent Full-Time Student

YesNo

Dependent Disabled

YesNo

2. Dependent/s Information

Dependent First Name

Dependent Last name

Dependent Social Security#

Dependent Relation

Dependent Date of Birth

Dependent Months in Home

Dependent Full-Time Student

YesNo

Dependent Disabled

YesNo

3. Dependent/s Information

Dependent First Name

Dependent Last name

Dependent Social Security#

Dependent Relation

Dependent Date of Birth

Dependent Months in Home

Dependent Full-Time Student

YesNo

Dependent Disabled

YesNo

4. Dependent/s Information

Dependent First Name

Dependent Last name

Dependent Social Security#

Dependent Relation

Dependent Date of Birth

Dependent Months in Home

Dependent Full-Time Student

YesNo

Dependent Disabled

YesNo

Relocation

Did you:

Move within the tax year?Live in another state?

DATE FROM

DATE TO

CITY

STATE

Income

Investments

Investments (1099-B, 1099-INT and 1099-DIV): Did you … *

Receive interest on savings, cash, U.S. Bonds or stock dividends (1099-INT/1099-DIV)?Sell stock, mutual funds, or other securities (1099-B)?Receive interest on a Partnership, S-Corp, Estate, or Trust (K1)?None

Upload 1099-INT/1099-DIVMax 8 MB per file.

Upload 1099-BMax 8 MB per file.

Upload K1Max 8 MB per file.

Retirement contributions

Contribute to a ROTH IRA $

Contribute to a Traditional IRA $

Contribute to a SEP $

Contribute to a Keogh $

Contribute to a Simple Retirement Plan $

Have a Health Savings Account (HSA)?

YesNo

Sell your home or any other property (equipment, land, etc.)?

YesNo

Please submit Sale of Property Intake Form.Max 8 MB per file.

Health coverage

Anything else

Upload any supporting financial documentsMax 8 MB per file.

Other Expenses