TAX PREP CLIENT INTAKE FORM

Filing Status

Single

Married Filing Seperate

Married Filing Joint

Qualifying Windower

Head of Household

TAXPAYER INFORMATION:

Full Name *

Date of birth

Phone *

Email *

SSN *

Address

City

State

Postal code

Occupation

Are you a full-time student?

Yes

No

Are you totally and permanently disabled?

Yes

No

Are you legally blind?

Yes

No

SPOUSAL INFORMATION

Spouse Full Name

Spouse Date Of Birth

Phone Number

Email Address

Spouse Occupation

Spouse SSN

Are they a full-time student?

Yes

No

Are they totally and permanently disabled?

Yes

No

Are they legally blind?

Yes

No

DEPENDANTS:

Enter your dependents here

Dependent One Name & DOB
Dependent One SSN
Dependent Two Name & DOB
Dependant Two SSN
Dependent Three Name & DOB
Dependent Three SSN
Dependent Four Name & DOB
Dependent Four SSN

TAX RELATED QUESTIONS:

Employment Status

Employment Status

Employed
Unemployed
Self-Employed
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Are you contributing to 401k or other pre-tax account?

Yes

No

Is this your first time opening a pre-tax account?

Yes

No

Are you currently renting?

Yes

No

What is the monthly rental amount?

Landlord Name & Address

Legal Deductions:

Enter the following expenses total amount

Medical & Dental Insurance
Doctor Expenses
Dental Expenses
Medical Expenses
Vision & Prescriptions
Medical Miles Driven
Cash Contributions
Non-Cash Contributions
Volunteer Contributions
Auto Miles Driven
Real Estate Tax
Car/Boat Taxes
State Income Tax
Primary Mortgage Interest
Investment Mortgage Interest
Accident, Fire, Theft & Natural Disasters
Sales/Entertainment
Office-In-Home Expenses
Business Travel
Vehicle Use for Business Miles
Operating Expenses
Repairs & Maintenance
Business Supplies
Business Taxes & Licenses
Business Meals
Other business expenses (Business insurance)
Student Loan Interest Taxpayer
Student Loan Interest Spouse
Utilities/Telephone
Rent or Lease Payments
Office Expenses
Legal & Professional Services
Car & Truck Expenses
Advertising
Education Expenses
Safe Deposit Box
Tax Return Preparation
Safety Shoes & Gloves
Union Dues
Work Tools
Dry Cleaning

Please upload the driver license of Taxpayer & Spouse:

Please upload all income documents (business & personal):

Please upload the social security card of Taxpayer & Spouse:

Please upload any deductions documents not listed on the Legal Deductions section of this form:

Please upload any College Tuition Statements & Statements from daycare providers:

Direct Deposit Information

Marketplace Health Insurance 1095A Form

Additional Comments

ACKNOWLEDGMENT & SIGNATURE

I confirmed that all information I entered here is accurate and true.
I allow D. Jefferson & Associates (DJ & A Tax Services) to capture my sensitive data like personal id, government id, social security number (SSN), and other information in order to prepare my tax returns.
I have read the terms and conditions and privacy policy of DJ & A Tax Services.
There are no refunds for services provided.
By signing below, you acknowledge that you have read and understood your responsibilities and our responsibilities in doing this tax return.

Date Signed

Taxpayer Signature

Clear

I agree to terms & conditions provided by the DJ & A Tax Prep Services. By providing my phone number, I agree to receive text messages from this business.