Tax Preparation Client Intake Form

Filing Status *

Single

Married Filing Separate

Qualifying Widower

Head of Household

Married Filing Joint

Taxpayer Information

First Name *

Last Name *

Date of birth *

Age *

Phone *

Please enter a valid phone number.

Email *

Address *

Street Address Line 2

City *

State / Province *

Postal / Zip Code *

Occupation *

SSN *

Are you a full-time student? *

Yes

Are you totally and permanently disabled? *

Yes

Are you legally blind? *

Yes

Is this individual dependent of another? *

Yes

Do you have health insurance within 12 months last year? If yes, who covers for it? *

Yes

Employer

Spouse Ins

Exchange/ Marketplace

Direct with Insurer

Medicare

Medicaid

Spouse Information

First Name

Last Name

Date of Birth

Age

Phone Number

Please enter a valid phone number.

Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Spouse Occupation

Spouse SSN

For Spouse - Are you a full-time student?

Yes

For Spouse - Are you totally and permanently disabled?

Yes

For Spouse - Are you legally blind?

Yes

For Spouse - Is this individual dependent of another?

Yes

Does your spouse have health insurance within 12 months last year? If yes, who covers for it?

Yes

Employer

Spouse Ins

Exchange/ Marketplace

Direct with Insurer

Medicare

Medicaid

Dependents

How many dependent/s you have?

-
1
2
3
4
5
6
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Dependent 1

Name

SSN

Date of Birth

Relationship

Does your dependent/s have health insurance within 12 months last year? If yes, who covers for it?

Yes

Employer

Spouse Ins

Exchange/ Marketplace

Direct with Insurer

Medicare

Medicaid

Is the dependent disabled?

Yes

Dependent 2

Name

SSN

Date of Birth

Relationship

Does your dependent/s have health insurance within 12 months last year? If yes, who covers for it?

Yes

Employer

Spouse Ins

Exchange/ Marketplace

Direct with Insurer

Medicare

Medicaid

Is the dependent disabled?

Yes

Dependent 3

Name

SSN

Date of Birth

Relationship

Does your dependent/s have health insurance within 12 months last year? If yes, who covers for it?

Yes

Employer

Spouse Ins

Exchange/ Marketplace

Direct with Insurer

Medicare

Medicaid

Is the dependent disabled?

Yes

Dependent 4

Name

SSN

Date of Birth

Relationship

Does your dependent/s have health insurance within 12 months last year? If yes, who covers for it?

Yes

Employer

Spouse Ins

Exchange/ Marketplace

Direct with Insurer

Medicare

Medicaid

Is the dependent disabled?

Yes

Dependent 5

Name

SSN

Date of Birth

Relationship

Does your dependent/s have health insurance within 12 months last year? If yes, who covers for it?

Yes

Employer

Spouse Ins

Exchange/ Marketplace

Direct with Insurer

Medicare

Medicaid

Is the dependent disabled?

Yes

Dependent 6

Name

SSN

Date of Birth

Relationship

Does your dependent/s have health insurance within 12 months last year? If yes, who covers for it?

Yes

Employer

Spouse Ins

Exchange/ Marketplace

Direct with Insurer

Medicare

Medicaid

Is the dependent disabled?

Yes

Tax Related Questions

Employment Status *

Employed

Self-employed

Unemployed

Are you applying for the cash advance up to $7,000? *

Yes

Are you contributing to 401k or other pre-tax account? *

Yes

Is this your first time opening a pre-tax account? *

Yes

Please select what state return are you requesting? *

State return

Local

Country returns

School

RITA

Does your dependents have tuition expenses? *

Yes

Do you have energy star rated improvements to your home?

Windows

Furnace

Doors

Other

Do you have any expenses for child care? *

Yes

Are you currently renting? *

Yes

What is the monthly rental amount?

How long have you been renting this property?

Do you have your own home? *

Yes

Do you have documents that shows you paid for property taxes? *

Yes

Did you sell any stock? *

Yes

Did you take money from your 401? *

Yes

Did you pay for vehicle tax? *

Yes

Do you have mortgage interest? *

Yes

Do you have real estate tax? *

Yes

Did you receive a federal tax refund last year? *

Yes

Are you a victim of identity theft? *

Yes

Expenses

Dependent Care/Child care: Name , Tax ID#, Business address, Phone#

General Expenses

Please fill-up the information within the current year only.

Medical Expenses

Dental Expenses

Insurance Premiums paid

Long Term Care Premiums

Prescription Drugs and Medications

Home Mortgage

Investment Interest

Cash Contributions

Non-Cash Contributions

Unreimbursed Business Expenses

Union Dues

Tax Preparation Fees

Investment Expenses

Total Expenses *

Do you need any of the following services? *

LLC

Business Credit

Life Insurance

Real Estate

Bookkeeping

Credit Restoration

Funeral Plan Assistance

Unsecured Loans

Tax Debt Resolution

Are you recieving government assistance ? *

Direct Deposit information (Bank name, routing and account number) *

File Upload/ Please upload your ID, children's Social Security Cards, W2's, 1099 NEC, etc *

Browse Files

Selfie *

Browse Files

FOR SECURITY REASONS PLEASE UPLOAD A SELFIE OF YOU HOLDING YOUR VALID GOVERNMENT ID

Acknowledgment & Signature

I confirm that all information I have entered here is accurate and true.

I give Sevyn Solutions consent 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 Sevyn Solutions.

By signing below, you acknowledge that you have read and understood your responsibilities and our responsibilities in doing this tax return.

This information will be used to prepare your taxes and will be sent to the IRS in case of an audit. In the event I am audited, I have substantial documentation to submit to the IRS.

Additionally, I understand that if my tax refund is garnished for any reason,

I am still responsible for the tax preparation fee. This fee, along with any loan advances issued by the bank, will be auto-debited via ACH using the account information. I have provided, regardless of the status of my refund.

Taxpayer Date Signed *

Taxpayer Signature *

Clear

Spouse Date Signed

Spouse Signature

Clear