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CLIENT INTAKE FOM

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Taxpayer FIRST and LASTNAME

Taxpayer Social Security Number

Taxpayer Date of Birth

Taxpayer Age

Taxpayer Phone Number *

Taxpayer Email *

Do you owe child support? Do you owe anything other than child support ? If so how much do you

What is the name of your business? Types of business and EIN

DEPENDENTS/ CHILDCARE

Dependents information

Dependents name /include suffix - social security number date of birth

Dependent Information (do not enter Middle Name)

Dependent 1

Name
Social Security
Date Of Birth

Dependent 2

Name
Social Security
Date Of Birth

Dependent 3

Name
Social Security
Date Of Birth

Dependent 4

Name
Social Security
Date of Birth

Child/ Dependent care expenses

Providers EIN/SSN

Providers Address city zip code

UPLOAD DOCUMENTS

File Upload For you and dependents

Please uploaded a valid ID and social security number card for and dependents

Dependent care provider name

I CERTIFY THAT I VERIFIED THE DIRECT BANKING INFORMATION AND UNDERSTAND AND THAT ONCE THE TAX RETURN HAD BEEN SUBMITTED BY THE TAX PREPARER NO CHANGE CAN BE MADE TO ANY OF THE BANK PAYOUT OPTION

I CERTIFY I WOULD LIKE TO HAVE MY TAX RETURN PREPARED IN ACCORDANCE WITH THE INFORMATION I HAVE PROVIVED

DATE SIGNED

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