Intake Form Home / Intake Form CLIENT INFORMATION Email Street Address: City: State: ZIP: FILING STATUS (CHECK ONE) CLIENT INFORMATION Single Head of Household Qualifying Widow(er) CLIENT INFORMATION Single Married Filing Jointly Married Filing Separately DEPENDENTS Name DOB SSN Relationship INCOME SOURCES (CHECK ALL THAT APPLY) CLIENT INFORMATION W-2 Unemployment Othe CLIENT INFORMATION 1099 / Self-Employed Retirement / Pension CLIENT INFORMATION SSI / Disability nterest / Dividends DOCUMENTS PROVIDED CLIENT INFORMATION Photo ID W-2 Last Year Return Childcare Expenses Student Loan Interest CLIENT INFORMATION Social Security Cards 1099 Bank Info Mortgage Interest Other DIRECT DEPOSIT INFORMATION (OPTIONAL) Bank Name: Routing Number: Account Number: FEE AGREEMENT & AUTHORIZATION Message AGREE to the $150 tax preparation fee plus the $15.99 state filing fee. AGREE to the $150 tax preparation fee plus the $15.99 state filing fee. Client Signature: Date: File Upload Submit