Client intake

FAST
First
Last
SSN#
Date of Birth
MonthDayYear
Date
Address
Street Address
Street Address Line 2
CityState / Province
Zip
Home Phone
Format: (000) 000-0000.
Mobile Phone
Format: (000) 000-0000.
YES
NO
Occupation
Email
example@example.com
YES
NO
MI
Last
SSN#
Date of Birth
MonthDayYear
Date
Occupation
YES
NO
Email
example@example.com
YES
Single
Do you have outstanding student loan?
YES
NO
Married Filing Joint
Do you owe back child support?
YES
NO
Married Filing Seperately
Are you current with your tax obligations?YES
YES
NO
Head of Household
Any other information we need to know
Qualifying Widower
Did everyone on this tax return have health insurance all 12 months last year? YES
YES
NO
Yes
NO
If yes, Coverage through (Circle one)
Employer
If not covered for all 12 months, Please provide Form 1095-A
Exchange/Marketplace
Direct with Insurer
NO
NO
Would you like your refund deposited into your bank account? YES
YES
NO
Routing #
Account#
Would you rather have your refund issued on a paper check or VISA debit card?YES
YES
NO
All the information on this form is true and correct to the
Signature
Clear
Date
MonthDayYear
Date
Should be Empty:

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