Tax Client Intake Form

Disclaimer: Thank you in being a client of Wea Tax Services. This form is used to collect information about new clients and is for internal purposes only. The information you provide is confidential and will be treated accordingly.

FILING STATUS Single
Married Filing Joint
Married Filing Single
Head of Household
Qualifying Widdower

TAX PAYER INFO Name:

Address:

City:

State:

Zip Code:

Email:

Phone:

Date of Birth:

Social Security #:

Occupation:

SPOUSE INFO Name:

Street Address:

Account #:

Route #:

City:

State:

Zip Code:

Email:

Phone:

Date of Birth:

Social Security #

Occupation:

DEPENDENTS

1st Dependent

Name:

Social Security #:

Date of Birth:

Relationship:

Student?
Yes No

2nd Dependent

Name:

Social Security #:

Date of Birth:

Relationship:

Student?
Yes No

3rd Dependent

Name:

Social Security #:

Date of Birth:

Relationship:

Student?
Yes No

4th Dependent

Name:

Social Security #:

Date of Birth:

Relationship:

Student?
Yes No

5th Dependent

Name:

Social Security #:

Date of Birth:

Relationship:

Student?
Yes No

INCOME Did you receive any W2 income?
Yes No

Did you receive any self-employment income?
Yes No

Did you receive income from rental property?
Yes No

Did you receive unemployment income?
Yes No

Did you receive any money from stock sales?
Yes No

Did you receive any interest or dividends?
Yes No

Did you receive any Social Security income?
Yes No

Did you receive any miscellaneous (1099) income?
Yes No

Did you receive any alimony?
Yes No

Did you receive any other income from assets sold?
Yes No

Did you take any money from your 401k?
Yes No

Did you receive any taxable refunds/credits/offsets?
Yes No

Did you receive any foreign income?
Yes No

Did you receive any other income?
Yes No
If yes, list other streams of income.

Adjustments to income:

Did you have any educator (teaching) expenses?
Yes No

Did you have any health savings account deductions?
Yes No

Did you have any moving expenses (Military only)?
Yes No

Did you pay for self-employed health insurance?
Yes No

Did you make contributions to a retirement plan?
Yes No

Did you have any student or tuition/fees deductions?
Yes No

Did you pay any alimony?
Yes No

DEDUCTIONS Do you have any mortgage interest?
Yes No

Did you pay any real estate tax?
Yes No

Did you pay any vehicle tax?
Yes No

Did you pay any childcare expenses?
Yes No

Did you have any other deductions or credits?
Yes No
If yes, list other deductions or credits.

PAYMENTS Did you file taxes last year?
Yes No

Did you owe the state last year?
Yes No

Did you pay the state last year?
Yes No

Do you owe the IRS?
Yes No
If yes, how much?.
$

Did you receive a federal refund last year?
Yes No

Have you received any letter from the IRS?
Yes No

Did you borrow funds for college tuition?
Yes No

Did you make any estimated payments toward this year's tax return?
Yes No
If yes, enter all payments made along with the dates:

MISCELLANEOUS Are you part of a business partnership or corporation?
Yes No

Are you an Armed Forces Reservist?
Yes No

Are you a victim of identity theft?
Yes No

Signature Name:

Date:

I accept the terms and conditions