NEW CLIENT INTAKE FORM

Tax Year *

Primary Tax Payer's Name *

Gender *

MALE

FEMALE

Primary Tax Payer's SSN *

Date Of Birth *

Primary Tax Payer's Occupation *

Primary Tax Payer's Current Phone *

Address

Current Address *

City *

State *

Postal code *

Primary Tax Payer's Email *

Did you have Marketplace Insurance? (Affordable Healthcare/ Obamacare) *

Yes

No

Filing Status *

Today's Date *

Primary Tax Payer's Signature *

Spouse Name

Gender

FEMALE

MALE

Spouse SSN

Spouse DOB

Spouse Occupation

Spouse Phone Number

Spouse Email

Bank Name *

Account Type *

Checking

Savings

Routing # *

Account # *

Child #1 NAME

Child #1 SSN

Child #1 DOB

Child #1 Relationship

Child #1 Months Lived With You

Child #2 NAME

Child #2 SSN

Child #2 DOB

Child #2 Relationship

Child #2 Months Lived With You

Child #3 NAME

Child #3 SSN

Child #3 DOB

Child #3 Relationship

Child #3 Months Lived With You

Child #4 NAME

Child #4 SSN

Child #4 DOB

Child #4 Relationship

Child #4 Months Lived With You

Spouse Signature

Spouse Date

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