IMMIGRATION Client Intake Form Please do not enter Social Security numbers on this form. We collect SSNs and ITINs for you and your dependents securely through our encrypted client portal or in person, never by web form or email. Personal Information: Full Name Date of Birth Email Address: Phone Number: Marital Status:SingleMarriedHead of HouseholdWidow/Widower Current Address: Street: City: State: ZIP: Dependents: Do you have dependents ?YesNo List dependents: (Full Name, Date of Birth, Relationship, Number of Months Living with You) 1 2 3 Income Information: Wages (W-2)Do you have W-2 forms from employers?YesNo Please attach copies of all W-2 forms received. Self-Employment or Freelance Income (1099-MISC or 1099-NEC) ?YesNo Please provide a summary of your income and expenses. Investment Income (e.g., Dividends, Interest, Capital Gains) ?YesNo Please provide relevant forms (e.g., 1099-INT, 1099-DIV, 1099-B). Other Income (Alimony, Rental, Pension, Social Security, etc.)YesNo Please provide documentation of any other income (e.g., 1099-R, SSA-1099). Deductions & Credits Do you want to itemize deductions?YesNo If yes, please provide supporting documents for the following: Mortgage interest (Form 1098) Property taxes paid Medical expenses Charitable contributions Other deductions (e.g., unreimbursed business expenses) Childcare or Dependent Care CreditYesNo Please provide receipts or documentation for any childcare or dependent care services. Education Credits (Lifetime Learning, American Opportunity Credit)YesNo Please provide Form 1098-T (Tuition Statement) or related records Health Insurance Do you have health insurance?YesNo If yes, please provide Form 1095-A, 1095-B, or 1095-C. Was anyone on your tax return covered under a Marketplace plan?YesNo If yes, please provide Form 1095-A. Other Tax Information Do you have any IRS notices or tax-related documents?YesNo If yes, please attach copies of any notices, prior year tax returns, or documents Additional Questions Would you like assistance with tax planning for the upcoming year?YesNo Do you expect any major life changes in the upcoming year (e.g., marriage, divorce, new dependents)?YesNo If yes, please explain: Signature I confirm that the information provided is true and accurate to the best of my knowledge. I understand that it is my responsibility to ensure all information is provided and accurate. Name: Date: Δ
