Intake Sheet Test

Intake Sheet PDF

<br />

Fill Out Digital Intake Form

Intake Form 2019

YOUR PERSONAL INFORMATION

Name(s)
*

Date
*

Social Security Number
*

First Name
*

Middle Name(s)/Maiden Name
*

Last Name
*

Date of Birth (MM/DD/YYYY)
*

Job Title
*

Phone Number with Area Code
*

Cell Phone Number
*

Text OK?

1 Yes

1 No

Mailing Address, City, State & ZIP Code
*

Email
*

A full-time student?

2 Yes

2 No

Getting Unemployment?

3 Yes

3 No

Paying dependent care expenses?

4 Yes

4 No

United States Citizen?

5 Yes

5 No

Can anyone claim you on their tax return?

6 Yes

6 No

Did you have Health Insurance?

7 Yes

7 No

Marital Status?
*

1 Single

2 Divorced

3 Legally Separated

4 Widowed

5 Married

If Divorced: Date of final Decree:

If Separate: Date of Separate maintenance agreement:

If Widowed: Year of Spouse's death

If Married: Did you get married in 2019?

If Married: Did you live with your spouse during any part of the last six months?

8 Yes

8 No

SPOUSE'S PERSONAL INFORMATION

Social Security Number

First Name

Middle Name(s)/Maiden Name

Last Name

Date of Birth (MM/DD/YYYY)

Job title

Phone Number with Area Code

Cell Phone Number

TEXT OK?

9 Yes

9 No

Mailing Address, City, State, & ZIP Code

A Full Time Student?

10 Yes

10 No

Getting Unemployment?

11 Yes

11 No

Paying dependent care expenses?

12 Yes

12 No

United States Citizen?

13 Yes

13 No

Can anyone else claim you on their tax return?

14 Yes

14 No

Did you have Health Insurance?

15 Yes

15 No

DEPENDENTS

Other than your spouse, list the names of everyone you provided more than 1/2 total support who lived with you last year. you can list up to 6. (You may skip this entire section if inapplicable)

Dependent 1 Name

Dependent 1 Social Security Number

Dependent 1 Date of Birth (MM/DD/YYYY)

Dependent 1 Relationship (Son, Daughter, Parent, etc.)

Dependent 1 Months lived in your home in 2019

Dependent 1 is a US Citizen?

16 Yes

16 No

Dependent 1 is Single or Married as of 12/31/2019?

1 Single

1 Married

Dependent 1 is a Full-Time Student?

17 Yes

17 No

Dependent 1 is Totally & Permanently Disabled? (IRS Form 524)

18 Yes

18 No

Dependent 2 Name

Dependent 2 Social Security Number

Dependent 2 Date of Birth (MM/DD/YYYY)

Dependent 2 Relationship (Son, Daughter, Parent, etc.)

Dependent 2 Months lived in your home in 2019

Dependent 2 is a US Citizen?

19 Yes

19 No

Dependent 2 is Single or Married as of 12/31/2019?

2 Single

2 Married

Dependent 2 is a Full-Time Student?

20 Yes

20 No

Dependent 2 is Totally & Permanently Disabled? (IRS Form 524)

21 Yes

21 No

Dependent 3 Name

Dependent 3 Social Security Number

Dependent 3 Date of Birth (MM/DD/YYYY)

Dependent 3 Relationship (Son, Daughter, Parent, etc.)

Dependent 3 Months lived in your home in 2019

Dependent 3 is a US Citizen?

22 Yes

22 No

Dependent 3 is Single or Married as of 12/31/2019?

3 Single

3 Married

Dependent 3 is a Full-Time Student?

23 Yes

23 No

Dependent 3 is Totally & Permanently Disabled? (IRS Form 524)

24 Yes

24 No

Dependent 4 Name

Dependent 4 Social Security Number

Dependent 4 Date of Birth (MM/DD/YYYY)

Dependent 4 Relationship (Son, Daughter, Parent, etc.)

Dependent 4 Months lived in your home in 2019

Dependent 4 is a US Citizen?

25 Yes

25 No

Dependent 4 is Single or Married as of 12/31/2018?

4 Single

4 Married

Dependent 4 is a Full-Time Student?

26 Yes

26 No

Dependent 4 is Totally & Permanently Disabled? (IRS Form 524)

27 Yes

27 No

Dependent 5 Name

Dependent 5 Social Security Number

Dependent 5 Date of Birth (MM/DD/YYYY)

Dependent 5 Relationship (Son, Daughter, Parent, etc.)

Dependent 5 Months lived in your home in 2019

Dependent 5 is a US Citizen?

28 Yes

28 No

Dependent 5 is Single or Married as of 12/31/2019?

5 Single

5 Married

Dependent 5 is a Full-Time Student?

29 Yes

29 No

Dependent 5 is Totally & Permanently Disabled? (IRS Form 524)

30 Yes

30 No

Dependent 6 Name

Dependent 6 Social Security Number

Dependent 6 Date of Birth (MM/DD/YYYY)

Dependent 6 Relationship (Son, Daughter, Parent, etc.)

Dependent 6 Months lived in your home in 2019

Dependent 6 is a US Citizen?

31 Yes

31 No

Dependent 6 is Single or Married as of 12/31/2019?

6 Single

6 Married

Dependent 6 is a Full-Time Student?

32 Yes

32 No

Dependent 6 is Totally & Permanently Disabled? (IRS Form 524)

33 Yes

33 No

Notes

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Stephens Tax Office Pros

Intake Sheet Test

YOUR PERSONAL INFORMATION

SPOUSE'S PERSONAL INFORMATION

DEPENDENTS

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Hours & Info

Stephens Tax Office Pros

Intake Sheet Test

YOUR PERSONAL INFORMATION

SPOUSE'S PERSONAL INFORMATION

DEPENDENTS

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Like this:

Hours & Info