Tax Prep Intake Form

Taxpayer Information
Please provide your information below.

Taxpayer Name

Occupation

Taxpayer Date of Birth

Cell Phone

Home Phone

Address

City, State and Zip Code

Email Address

Spouse Information
Please provide your spouse information below.

Spouse Name

Spouse Occupation

Spouse Date of Birth

Spouse Address (if differs from yours)

City, State and Zip Code

Spouse Email Address

Did you or your spouse attend college this tax year?

YesNo

Are you legally blind?

Is your spouse legally blind?

Are you permanently disabled?

YesNo

Is your spouse permanently disabled?

YesNo

Please confirm your Filing Status below by checking off one category. All of the filing status categories below are based upon your status as of December 31st (the last day of the tax year). 1) Single – You are single if you were not married and you are claiming no dependents.2) Married Filing Joint – You are MFJ if both you and your spouse have agreed to file a joint return.3) Married Filing Separate – You are MFS if you would like to be responsible for your own tax.4) Head of Household – You are not married (or are legally separated) and you are claiming at least one dependent.5) Widow with dependent child – You can claim this filing status if your spouse died in 2010 or 2009 and you have not remarried and you have a qualifying dependent.

Can anyone else claim you as a dependent on their tax return?

YesNo

Can anyone else claim your spouse as a dependent on their tax return?

YesNo

Dependent Information: Please provide your dependent(s) information below.

Dependent #
Full Name

Date of Birth

Relationship

How many months child lived in home?

Child Care Expenses?

Are any of your dependents legally disabled?
YesNo

Child Care Provider Information

Child Caregiver #
Provider's Name, Address & Phone Number:

SNN or Federal Identification Number (EIN):

Amount paid:

Income
Please indicate if you have received any of the following:
UnemploymentAlimonyS.S. BenefitsGamblingSelf Employment Income Interest or Dividends1099 IncomeUnreported Tip Income Other Income

Add additional information here:

Itemized Deductions:

Do you own a home?

YesNo

Provide us with mortgage interest and property taxes amount paid this tax year.

Did you make any Charitable Contributions?

YesNo

If so, please list expense amount here:

Did you have any Medical Expenses?

YesNo

If so, please list expense amount here:

Un-reimbursed business expenses?

YesNo

If so, please provide the details:

Earned Income Credit Due Diligence Worksheet

Is your filing status “Married Filing Separate?”

YesNo

Do you and your spouse have a Social Security Number that allows you to work?

YesNo

Is your investment income less than $3,200?

YesNo

Can anyone else claim you as a qualifying child?

YesNo

Were you a U.S. Citizen or resident alien for the entire year?

YesNo

This section to be filled out by taxpayers with dependents only.

Dependent : is my son, daughter, stepchild, foster child, brother, sister, stepbrother, stepsister, half brother, half sister, or a descendant of any of them?

Will this dependents file their own return as Married Filing Joint?

Did your dependent live with you for over half the year?

Can any other taxpayer claim your dependent on their tax return?

If NO please continue, if YES, is your modified Adjusted Gross Income (AGI) higher than any other taxpayer

This section is to be filled out by taxpayers without dependents:

Was your main home in the United States for more than half the year?

YesNo

Were you, or your spouse if filing Jointly, at least 25 but not more than 65 at the end of the year?

YesNo

Are you eligible to be claimed as a dependent on anyone else’s tax return?

YesNo

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