TAX CLIENT INTAKE FORM

Filing Status *

TAXPAYER INFORMATION:

Full Name *

Social Security Number *

Date of birth *

Phone *

Email *

Occupation

Street Address *

City

State

Country

Postal code

Are you a full-time student? *

Yes

No

Are you legally blind? *

Yes

No

Are you totally and permanently disabled? *

Yes

No

Spouse Full Name (add NA to all boxes if they do not apply)

Spouse Social Security Number

Spouse Date Of Birth

Phone Number

Email Address

Spouse Occupation

Are they a full-time student?

Yes

No

Are they legally blind?

Yes

No

Are they totally and permanently disabled?

Yes

No

DEPENDANT(S):

Dependent Name, DOB, Full SS# , Relationship

Dependent 1

Male

Female

Dependent Name, DOB, Full SS# , Relationship

Dependent 2

Male

Female

Dependent Name, DOB, Full SS#, Relationship

Dependent 3

Male

Female

Dependent Name, DOB, Full SS# , Relationship

Dependent 4

Male

Female

TAX RELATED QUESTIONS:

Do you have outstanding IRS debt? (Federal/State) *

Yes

No

Are you planning to purchase/refinance a home? *

Yes

No

Did the primary taxpayer receive a Form 1095-A Health Insurance Marketplace Statement? *

Yes

No

At any time during the year, did you receive, sell, send, exchange, or otherwise acquire an financial interest in a virtual currency? *

Yes

No

GENERAL EXPENSES:

Enter the following expenses total amount

Medical Expenses
Dental Expenses
Long Term Care Premiums
Prescription Drugs and Medications
Cash Contributions
Non-Cash Contributions

Charity/Donations

Childcare (Provider, EIN, Address, Amount)

Account to Deposit Refund *

Routing Number *

Account Number *

This payment is for consulting services (credit card information required) *

Cardholder Name *

Cardholder Billing Address *

Credit/Debit Care Number *

Expiration Date *

CVV *

ACKNOWLEDGMENT & SIGNATURE

I confirmed that all information I entered here is accurate and true.
I allow Quintessential Group Consulting Services to capture my sensitive data like personal id, government id, social security number (SSN), and other information.
I have read the terms and conditions and privacy policy of Quintessential Group Consulting Services.
By signing below, you acknowledge that you have read and understood your responsibilities and our responsibilities in doing this tax return.

Taxpayer Signature *

Clear

Spouse Signature

Clear

Date Signed *

Captcha

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.

Supporting Documents *

Upload all tax documents, and IDs