(817) 726-2181

New / Current Client Intake Form

You will need:
  • Tax Information such as Forms W-2, 1099, 1098, 1095.
  • Social security cards or ITIN letters for all persons on your tax return.
  • Picture ID (such as valid driver's license) for you and your spouse.
  • You are responsible for the information on your return. Please provide
    complete and accurate information
Part I – Your Personal Information (If you are filing a joint return, enter your names in the same order as last year’s return)

M.I.


YesNo

M.I.


YesNo

Apt #




A. Full-time student   

YesNo 		B. Totally and permanently disabled

YesNo		 C. Legally blind

YesNo


A. Full-time student   


YesNo 		B. Totally and permanently disabled

YesNo		 C. Legally blind

YesNo

YesNoUnsure
A. Been a victim of identity theft?

YesNo 		B. Adopted a child?

YesNo
Part II – Marital Status and Household Information
Never Married (This includes registered domestic partnerships, civil unions, or other formal relationships under state law)
Married A. If Yes, Did you get married in 2019?         YesNo

B. Did you live with your spouse during any part of the last six months of 2019?         YesNo
Divorced Date of final decree
Legally Separated Date of separate maintenance agreement
Widowed Year of spouse’s death

  • Everyone who lived with you last year (other than your spouse)
  • Anyone you supported but did not live with you last year
Name (first, last) Do not enter your name or spouse’s name below

(a)		 Date of Birth (mm/dd/yy)

(b)		 Relationship to you (for example: son, daughter, parent, none, etc)

(c)		 Number of months lived in your home last year

(d)		 US Citizen (yes/no)

(e)		 Resident of US, Canada, or Mexico last year (yes/no)

(f)		 Single or Married as of 2019 (S/M)

(g)		 Full-time Student last year (yes/no) (h) Totally and Permanently Disabled (yes/no) (i)
Check appropriate box for each question in each section
Yes No Unsure Part III – Income – Last Year, Did You (or Your Spouse) Receive
Yes No Unsure 1. (B) Wages or Salary? (Form W-2) If yes, how many jobs did you have last year?     
Yes No Unsure 2. (A) Tip Income?
Yes No Unsure 3. (B) Scholarships? (Forms W-2, 1098-T)
Yes No Unsure 4. (B) Interest/Dividends from: checking/savings accounts, bonds, CDs, brokerage? (Forms 1099-INT, 1099-DIV)
Yes No Unsure 5. (B) Refund of state/local income taxes? (Form 1099-G)
Yes No Unsure 6. (B) Alimony income or separate maintenance payments?
Yes No Unsure 7. (A) Self-Employment income? (Form 1099-MISC, cash)
Yes No Unsure 8. (A) Cash/check payments for any work performed not reported on Forms W-2 or 1099?
Yes No Unsure 9. (A) Income (or loss) from the sale of Stocks, Bonds or Real Estate? (including your home) (Forms 1099-S,1099-B)
Yes No Unsure 10. (B) Disability income? (such as payments from insurance, or workers compensation) (Forms 1099-R, W-2)
Yes No Unsure 11. (A) Payments from Pensions, Annuities, and/or IRA? (Form 1099-R)
Yes No Unsure 12. (B) Unemployment Compensation? (Form 1099G)
Yes No Unsure 13. (B) Social Security or Railroad Retirement Benefits? (Forms SSA-1099, RRB-1099)
Yes No Unsure 14. (M) Income (or loss) from Rental Property?
Yes No Unsure 15. (B) Other income? (gambling, lottery, prizes, awards, jury duty, Sch K-1, royalties, foreign income, etc.) Specify     
Yes No Unsure Part IV – Expenses – Last Year, Did You (or Your Spouse) Pay
Yes No Unsure 1. (B) Alimony or separate maintenance payments? If yes, do you have the recipient’s SSN?    
YesNo
Yes No Unsure 2. Contributions to a retirement account?
     IRA (A)    401K (B)  
  Roth IRA (B)     Other
Yes No Unsure 3. (B) College or post secondary educational expenses for yourself, spouse or dependents? (Form 1098-T)
Yes No Unsure 4. (B) Unreimbursed employee business expenses? (such as uniforms or mileage)
Yes No Unsure 5. (B) Medical expenses? (including health insurance premiums)
Yes No Unsure 6. (B) Home mortgage interest? (Form 1098)
Yes No Unsure 7. (B) Real estate taxes for your home or personal property taxes for your vehicle? (Form 1098)
Yes No Unsure 8. (B) Charitable contributions?
Yes No Unsure 9. (B) Child or dependent care expenses such as daycare?
Yes No Unsure 10. (B) For supplies used as an eligible educator such as a teacher, teacher’s aide, counselor, etc.?
Yes No Unsure 11. (A) Expenses related to self-employment income or any other income you received?
Yes No Unsure 12. (B) Student loan interest? (Form 1098-E)
Yes No Unsure Part V – Life Events – Last Year, Did You (or Your Spouse)
Yes No Unsure 1. (HSA) Have a Health Savings Account? (Forms 5498-SA, 1099-SA, W-2 with code W in box 12)
Yes No Unsure 2. (A) Have debt from a mortgage or credit card cancelled/forgiven by a commercial lender? (Forms 1099-C, 1099-A)
Yes No Unsure 3. (A) Buy, sell or have a foreclosure of your home? (Form 1099-A)
Yes No Unsure 4. (B) Have Earned Income Credit (EIC) or other credits disallowed in a prior year? If yes, for which tax year?
Yes No Unsure 5. (A) Purchase and install energy-efficient home items? (such as windows, furnace, insulation, etc.)
Yes No Unsure 6. (B) Live in an area that was affected by a natural disaster? If yes, where?
Yes No Unsure 7. (A) Receive the First Time Homebuyers Credit in 2008?
Yes No Unsure 8. (B) Make estimated tax payments or apply last year’s refund to this year’s tax? If so how much?
Yes No Unsure 9. (A) File a federal return last year containing a “capital loss carryover” on Form 1040 Schedule D?
Yes No Unsure Part VI - Health Care Coverage - Last year, did you, your spouse, or dependent(s)
Yes No Unsure 1. (B) Have health care coverage?
Yes No Unsure 2. (B) Receive one or more of these forms? (Check the box)     Form 1095-BForm 1095-C
Yes No Unsure A) Have coverage through the Marketplace (Exchange)? [Provide Form 1095-A]

  • 3a. (A) If yes, were advance credit payments made to help you pay your health care premiums?
  • 3b. (A) If yes, Is everyone listed on your Form 1095-A being claimed on this tax return?
Yes No Unsure 4. (B) Have an exemption granted by the Marketplace?


Visit http://www.healthcare.gov/ or call 1-800-318-2596 for more information on health insurance options and assistance.

If advance payments of the premium tax credit were paid on your behalf to help pay your health insurance premiums, you should report life changes, such
as, income, marital status or family size changes, to your Marketplace. Reporting changes will help to make sure you are getting the proper amount of
advance payments.


1. Provide an email address (optional) (this email address will not be used for contacts from the Internal Revenue Service)
2. If you are due a refund, would you like:
a. Direct deposit

YesNo
b. To purchase U.S. Savings Bonds

YesNo
c. To split your refund between different accounts

YesNo
3. If you have a balance due, would you like to make a payment directly from your bank account?     YesNo
4. Have you or your spouse received any letters from the Internal Revenue Service?     YesNo


Checking Account #
Saving Account #
Name of Bank:
Routing #


Signature of Taxpayer:      Signature of Spouse:     
Additional Tax Preparer notes:
Taxpayer:
Presidential Election Campaign Fund (If you check a box, your tax or refund will not change) Check here if you, or your spouse if filing jointly, want $3 to go to this fund    		Spouse:
Presidential Election Campaign Fund (If you check a box, your tax or refund will not change) Check here if you, or your spouse if filing jointly, want $3 to go to this fund   
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IRS Circular 230 Disclosure

To ensure compliance with requirements imposed by the IRS, we inform you that any U.S. tax advice contained in this communication (including any attachments) is not intended or written to be used, and cannot be used, for the purpose of (i) avoiding penalties under the Internal Revenue Code or (ii) promoting, marketing or recommending to another party any transaction or matter addressed herein.

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