Intake Form

Save & Return

Save your progress and complete this form later. (optional)

Who referred you? If no one type "none." *

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

DOB *

SSN *

Driver's License Number *

Driver's License State *

Driver's License Expiration Date *

Are you blind? *

Active Duty Military *

Can you be claimed as a dependent on someone else's return? *

Filing Status *

Number of Dependents *

Do you? *

Own

Rent

Spousal Information

First Name

Last Name

Street Address

Address Line 2

City

State

Zip Code

Phone Number

Email Address

DOB

SSN

Driver's License Number

Driver's License State

Driver's License Expiration Date

Can this person be claimed as a dependent on someone else's return?

Is this person active duty Military?

Is this person blind?

DEPENDENTS

First Name

Last Name

Relationship to Primary tax payer:

DOB

SSN

Months in Home

Can this child be claimed as a dependent by anyone else?

Name of Dependent's School

Disabled?

SECOND DEPENDENT

First Name

Last Name

Relationship to primary taxpayer

DOB

SSN

Months in Home

Can this child be claimed as a dependent by anyone else?

Name of Dependent's School

Disabled?

THIRD DEPENDENT

First Name

Last Name

Relationship to primary taxpayer

DOB

SSN

Months in Home

Can this child be claimed as a dependent by anyone else?

Name of Dependent's School

Disabled?

ADDITIONAL TAX CREDITS QUESTIONNAIRE

Did you:

Pay someone to watch your child (ren)? *

Receive unemployment compensation (2015)? *

Have income other than your W2(s)? *

Get a student loan or make college payments? *

Do you owe any delinquent:

Child Support? *

Alimony? *

Student Loans? *

Back Taxes? *

HEALTHCARE QUESTIONS

Did everyone in your household have health insurance for 2015 *

If not how many months were uncovered

Which month's were not covered? 🛈

Who did not have coverage?

Please explain why the person did not have coverage.

REFUND

WHEN DO YOU WANT YOUR REFUND? (Associated bank fees will be charged) *

7 - 14 days (RT-Refund Transfer: Check)

7 - 14 days (RT-Refund Transfer: Debit Card)

7 - 14 days (RT-Refund Transfer: Direct Deposit)

THE FOLLOWING PRODUCTS REQUIRE FEES PAID AT TIME OF SERVICE.

E-file: Direct Deposit

3 - 4 Weeks (E-file: Check)

Mail A Paper Return

By signing below I certify that all information above is true and accurate to the best of my knowledge. Falsification could result in penalty from the IRS.

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