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INTAKE FORM

(Examples: Uber, DoorDash, hair, lashes, photography, childcare, construction, online sales, etc.)
(e.g., Uber, DoorDash, hair stylist, construction, etc.)?

GENERAL INFORMATION

Take a clear photo on a flat, well-lit surface.
Place the ID on a flat surface and take a well-lit, straight-on photo.

INCOME

Take a clear photo on a flat, well-lit surface.
Form 1099-INT (Interest Income), Form 1099-DIV (Dividends), Form 1099-NEC / 1099-MISC (Contract or Self-Employment Income). Take a clear photo or scan on a flat, well-lit surface.
Take a clear photo on a flat, well-lit surface.
Form 1095-A (Marketplace/Healthcare.gov), Form 1095-B (Private or State Insurance), Form 1095-C (Employer-Provided Insurance) Take a clear photo on a flat, well-lit surface.
Take a clear photo on a flat, well-lit surface.

Spouse Information

Take a clear photo on a flat, well-lit surface.
Take a clear photo on a flat, well-lit surface.

DEPENDENT INFORMATION

Full Legal Name, Date Of Birth, Relationship Example: Son, Daughter, Niece, Grandchild, etc.
Full Legal Name, Date Of Birth, Relationship Example: Son, Daughter, Niece, Grandchild, etc.
Full Legal Name, Date Of Birth, Relationship Example: Son, Daughter, Niece, Grandchild, etc.
Full Legal Name, Date Of Birth, Relationship Example: Son, Daughter, Niece, Grandchild, etc.
Take a clear, well-lit photo on a flat surface.

SELF EMPLOYED

(If applicable — enter the name used on business documents or tax forms)
(If you do not have an EIN, leave blank or write “N/A.”)
(Use your business’s official mailing address. If home-based, enter your home address If you do not have an address, leave blank or write “N/A.”. )
(Enter your total business income before expenses — include all sales, payments, or deposits received.)
(Enter the total amount you earned before any expenses or deductions. This includes all business, contract, or self-employment income.)
Take a clear, well-lit photo on a flat surface showing all details. Blurry or incomplete images may delay processing.
(Example: “2 years,” “Since 2019,” or “Started in June 2023.”)
(Example: Hair styling, trucking, childcare, lawn care, consulting, cleaning services, etc.)
Take a clear, well-lit photo on a flat surface showing all details.
Take a clear, well-lit photo on a flat surface showing all details.
Take a clear, well-lit photo on a flat surface showing all details.

Acknowledgement