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Intake

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2020-2021 Tax Intake Form Intake Page 1 of 8 (or ______)
FILING STATUS
☐ Single
☐ Married Filing Joint
☐ Married Filing Single
☐ Head of Household
☐ Qualifying Widower
ADDRESS
Street & Apt. No. _________________________________
City _______________ State ___________ Zip _________
County ________________ School Code (if app) ________
TAXPAYER
Social Security Number ____________________________
First _____________ MI _____ Last __________________
Email __________________________________________
Work Ph ________________ Cell/Other ______________
Date of Birth ____________ Date of Death ____________
Preferred Method of Contact ☐ Email ☐ Phone ☐ Text
Occupation _____________________________________
☐ Yes ☐ No Legally Blind ☐ Yes ☐ No Dependent of Other
SPOUSE
Social Security Number ____________________________
First _____________ MI _____ Last __________________
Email __________________________________________
Work Ph ________________ Cell/Other ______________
Date of Birth ____________ Date of Death ____________
Preferred Method of Contact ☐ Email ☐ Phone ☐ Text
Occupation _____________________________________
☐ Yes ☐ No Legally Blind ☐ Yes ☐ No Dependent of Other
EMPLOYMENT & RETIREMENT INFORMATION
1. ☐ Yes ☐ No - Are you employed?
2. ☐ Yes ☐ No - Are you contributing to a 401(k), 403(b), or other pre-tax account?
3. ☐ Yes ☐ No - Have you ever opened any form of pretax account in the past?
4. ☐ Yes ☐ No - Have you considered a ROTH conversion of pretax accounts?
5. ☐ Yes ☐ No - Would you like a ROTH conversion tax “WHAT-IF” prepared with your return?
DEPENDENTS (INCLUDING NON-CHILD DEPENDENTS)
First, Middle Initial, Last Name Student? D.O.B Social Security # Disabled? Relationship
_________________________ ☐ Yes ☐ No _____________ ________________________ ☐ Yes ☐ No __________________
_________________________ ☐ Yes ☐ No _____________ ________________________ ☐ Yes ☐ No __________________
_________________________ ☐ Yes ☐ No _____________ ________________________ ☐ Yes ☐ No __________________
_________________________ ☐ Yes ☐ No _____________ ________________________ ☐ Yes ☐ No __________________
STATE & OTHER
1. ☐ Yes ☐ No - Are you requesting state return(s)? If yes, what state(s): ____________________________________
2. ☐ Yes ☐ No - Are you requesting local, school, RITA, or county return(s)? Please Specify: _____________________
AFFORDABLE CARE ACT
☐ Yes ☐ No Did everyone on this tax return have health insurance coverage all 12 months last year?
☐ Yes ☐ No If no, were you exempt? If yes, coverage through (select one)
Taxpayer: ☐ Employer ☐ Spouse Ins . ☐ Exchange/Marketplace ☐ Direct with Insurer ☐ Medicare ☐ Medicaid ☐ Exempt
Spouse: ☐ Employer ☐ Spouse Ins. ☐ Exchange/Marketplace ☐ Direct with Insurer ☐ Medicare ☐ Medicaid ☐ Exempt
Dep 1: ☐ Employer ☐ Spouse Ins . ☐ Exchange/Marketplace ☐ Direct with Insurer ☐ Medicare ☐ Medicaid ☐ Exempt
Dep 2: ☐ Employer ☐ Spouse Ins . ☐ Exchange/Marketplace ☐ Direct with Insurer ☐ Medicare ☐ Medicaid ☐ Exempt
Tax Client Income and Expense Questions Intake Page 2 of 8
Please Note: The following worksheets are intended to assist the taxpayer in gathering the information necessary for the preparer to complete an accurate tax return. For each
area the taxpayer has checked a box below, there should be corresponding back-up provided. There is a "Scan Coversheet" available by separate download that will provide
the preparer the list of documents necessary to complete the return. It is very important that the taxpayer provide complete information upon the first submission of these
documents. The below checklist provides basic information. There very well could be more information needed to be supplied. For situations that are beyond the information
provided below, please make sure detailed notes are provided to assist the preparer in determining the proper way to account for the situation. Missing information will delay
the processing of the return. Please do not leave any worksheet blank. If not applicable write "N/A" on that page and leave in stacking order. If additional pages are added
beneath a worksheet, write "see next xx pages" and correct "Intake Pg 1 of 8" to the correct total number of pages.
BASIC QUESTIONS
Please check the box to the left for any of the following that apply. If not, leave blank. If checked, please provide a brief explanation below if the
information will assist the preparer in any way. (Note: Please check for you AND your spouse)
01.☐ Did your marital status change from the prior year?
02.☐ Did you change your address from last year?
03.☐ Any change in your dependents from last year?
04.☐ Did you have children under 19 (or 24 if a full time student) who had more than $2,200 in total unearned income?
05.☐ Are all your dependents either US residents or citizens?
06.☐ Did you pay any adoption expenses?
07.☐ Did you provide over half the support for someone you aren't claiming as a dependent?
08.☐ Are you being claimed or eligible to be claimed as a dependent on someone else's return?
09.☐ Were either you or your spouse in the military or National Guard?
10.☐ Did you purchase, sell or refinance your primary residence?
11.☐ Have you been notified by the IRS of changes to a previously submitted tax return, or received any other IRS or state notices?
12.☐ Did you make any gifts over $15,000 to any individuals?
13.☐ Did you buy and/or sell any virtual currency (ie Bitcoin, Ether, Roblox, etc.)? If so, please provide all transaction details to preparer
Details: ________________________________________________________________________________________________________________
INCOME
Please check any of the following that you and/or your spouse received:
01.☐ W-2 Income
02.☐ Interest and/or Dividends
03.☐ Tax Exempt Interest and/or Dividends
04.☐ Taxable refunds, credits or offsets (including prior year state refunds)
05.☐ Business income (self-employment Income)
*If “yes” please fill out Schedule C worksheet and provide financials
06.☐ Stock sales (capital gains)- (MAKE SURE ALL BASIS INFO IS PROVIDED)
Amount of any capital loss carryforward from 2019 $_______________
07.☐ Any other assets sold or any other gains or losses
08.☐ Rental real estate income
* If "yes" please fill out Schedule E worksheet
Amount of any passive activity loss carryforward from 2019 $_______________
09.☐ K-1's (1120S, 1065, 1041)
10.☐ Unemployment
11.☐ Social Security income
12.☐ Foreign income
13.☐ Alimony (Applies ONLY to divorce decrees effective prior to 1/1/19)
Alimony received $_______________ (rcvd from whom?)
Name/SS#_______________________________________________________________
14. ☐ Other income: Please list: ____________________________________________
TAX DEDUCTIONS AND CREDITS
For the following, please check any of the following
that apply:
01.☐ Itemized deductions
*if “yes” please fill out a Schedule A worksheet
02.☐ Energy efficiency related upgrades/repairs
03.☐ Oil & Gas investments credits
04.☐ Other tax shelters or credits
05.☐ Child care expenses paid $_______________
Provider name:_____________________________
Address:___________________________________
Provider EIN:_______________________________
ADJUSTMENTS TO INCOME
Please check any of the following that apply to you and/or your spouse:
01.☐ Educator expenses (teaching expenses)
02.☐ Health Savings Account deductions
03.☐ Moving expenses (active military only, service related)
04.☐ Contributions to SEP, SIMPLE, and other qualified plans
05.☐ Self-Employed health insurance
06.☐ IRA contributions
07.☐ Student loan and/or tuition & fees deduction (you or your dependents)
08.☐ Alimony (Applies ONLY to divorce decrees effective prior to 1/1/19)
Alimony paid $_______________ (paid to whom?)
Name/SS#_______________________________________________________________
CARES Act Questionnaire for 1040 Tax Returns Intake Page 3 of 8
CARES Act PL116-136, March 27, 2020 & Tax Cuts and Jobs Act PL115-97 December 22, 2017
01. ☐ Yes ☐ No: For W-2 employees, were you mandated to work from home by your employer due to COVID?
If Yes:
☐ Yes ☐ No: Is/was your home in a different state than your normal workplace?
☐ Yes ☐ No: Did your state withholding change on your W-2 after you started working from home?
☐ Yes ☐ No: Did you start new withholding in your state of residence after being sent home to work?
☐ Yes ☐ No: Do you intend to file tax returns in multiple states?
02. ☐ Yes ☐ No: Did you contribute to a Qualified Opportunity Zone Fund between January 1st and July 15th, 2020?
03. ☐ Yes ☐ No: Did you take money from a 401(k), IRA or other pre-tax account in 2020?
If Yes, was the withdrawal related to one of these qualifying events:
☐ Yes ☐ No: You, your spouse or your dependent had COVID
☐ Yes ☐ No: You were furloughed, laid off, hours reduced or you were unable to work due to daycare closure as a result of COVID
04. ☐ Over 3 years ☐ one year ☐ other: How do you want the income recognized?
05. Did you make charitable contributions in 2020? If yes, how much? $______________ (up to $300 may be deducted even if you
don’t itemize)
06. ☐ Yes ☐ No: Did you contribute more than 60% of your income to a qualified charity in the form of cash in 2020?
If Yes, you may elect to eliminate the 60% limitation for cash contributions in 2020, and may deduct up to 100% of your Adjusted
Gross Income.
☐ Yes ☐ No: I would like to eliminate the 60% limitation and deduct up to ______% of my Adjusted Gross Income
Complete this section if you own a business (use separate sheets if you own more than one):
Name of Business: __________________________________________________________________________
07. ☐ Yes ☐ No : Did you apply for and receive a Paycheck Protection Program (PPP) Loan?
If No:
☐ Yes ☐ No: Did you use or do you intend to use the Employee Retention Tax Credit to offset wages and healthcare paid between
3/12/20 and 12/31/20?
08. ☐ Yes ☐ No : Did you use or take advantage of the WOTC (Work Opportunity Tax Credit) or did you receive a tax credit for paid sick
and family leave under FFCRA (Families First Coronavirus Response Act)?
09. If you did receive a PPP loan, how much did you receive? $___________________
10. ☐ Yes ☐ No : Did you include those loan proceeds in your company revenue?
11. ☐ Yes ☐ No : Did you apply for and receive loan forgiveness in 2020?
If Yes, amount forgiven? $_______________
12. ☐ Yes ☐ No : Did you apply for and receive an Economic Injury Disaster Loan (EIDL) through SBA?
If Yes, amount forgiven? $_______________
13. ☐ Yes ☐ No : Did you include those loan proceeds in your company revenue?
14. ☐ Yes ☐ No : Did you apply for and receive loan forgiveness in 2020?
If Yes, amount forgiven? $_______________
15. ☐ Yes ☐ No : Did your business experience a net operating loss for 2018, 2019 or 2020?
16. ☐ Yes ☐ No : Did you elect to defer payments to the IRS of the ER side of FICA in 2020?
17. ☐ Yes ☐ No : Did you experience full or partial shutdown of your business or have a significant decline in gross receipts due to
government orders related to COVID?
ID is Required for ALL Returns! At Least One MUST Be Photo! Intake Page 4 of 8
Two forms of ID for each taxpayer are strongly recommended, but at least one is required, which MUST be a photo ID. Second ID may be
photo or not. Use this page if you would like to gather IDs and voided check together in one place and copy. Use COLOR setting when
making the copy, even though the complete Intake Form will be scanned in black and white, as this will make for a better image for the
scanner. If IDs and voided check will be separate documents, simply place those documents between this page and the next Intake page
and change the first Intake page from “Page 1 of 8” to “Page 1 of (correct total number of pages)”.
PHOTO ID - REQUIRED
PHOTO ID - REQUIRED
1 Other Form of ID - Optional
Place Voided Check Here if Client Wants Direct Deposit
1 Other Form of ID - Optional
TAX Client Schedule A Info Intake Page 5 of 8
Fill out COMPLETELY or mark “N/A”. Please DO NOT leave blank. Include any back-up documents under Scan Coversheet
Medical Expenses Current Year
Medical & Dental Expenses $____________________________
Medical Insurance Premiums Paid $____________________________
Long Term Care Premiums $____________________________
☐ Yes ☐ No Fed Deductible? ☐ Yes ☐ No State Deductible? ☐ Yes ☐ No Not Qualified but Grandfathered Deductible?
Prescription Drugs and Medications $____________________________
Medical Miles Driven ____________________________
Tax Expenses* Current Year * Effective 1/1/2018, Total Tax deduction limited to $10,000
State/Local Income Taxes Paid
(Other Than those on W-2s, 1099s, Etc.) $____________________________
2019 State Income Taxes Paid in 2020 $____________________________
Real Estate Taxes $____________________________
Personal Property Taxes $____________________________
Qualified New Vehicle Taxes $____________________________
Additional State or Local/Taxes $____________________________
Other Taxes: _______________________ $____________________________
Interest Expense Current Year
Home Mortgage Interest reported on form 1098 $____________________________ Include Form under Scan Cover Sheet
Date Mortgage Contracted* __________________ (Only needed for jumbo mortgages over $750,000)
Date Mortgage Closed* __________________ (Only needed for jumbo mortgages over $750,000)
Home Mortgage Interest paid to others $____________________________
HELOC Interest Used for Home Improvement $____________________________
Refinancing Points Paid in 2020 $____________________________
Investment Interest (other than K-1) $____________________________
☐ Yes ☐ No Would you like to learn how to pay off your mortgage early?
Contributions Current Year
Cash Contributions $____________________________
Non-Cash Contributions $____________________________
Volunteer Mileage Driven ____________________________
Casualty & Theft Losses – Related to Federally-declared Disaster ONLY
If you had any casualty or theft losses during the year, please provide detail below: Including date, description, amount of
casualty or loss, any insurance reimbursement and basis in the property.
____________________________________________________________________________________________________
____________________________________________________________________________________________________
_
Tax Client Schedule C Info - One Form Per Business Intake Page 6 of 8
Fill out COMPLETELY or mark “N/A”. Please DO NOT leave blank. Use a separate Worksheet for EACH Schedule C.
**Please Note: If Possible, it is preferred a Trial Balance, P&L and Balance Sheet be provided by the client. If available, write “See next XX
Pages” Below and stack under this page. If not available, please use the input sheet below.
Business Info: (Required for all)
☐ Taxpayer or ☐ Spouse Address of Business: _____________________________
_____________________________
Name of Business: ________________________ Business Code: _____________________________
EIN Number (If any): ________________________ Date Business Started: ____________________________
☐ Cash Accounting Method ☐ Yes ☐ No Do you do your own books/accounting
☐ Accrual ☐ Yes ☐ No Would you consider outsourcing to us?
☐ Other(Specify): ____________________ ☐ Yes ☐ No Are you a specified Service Trade or Business
(eg: attorneys, accountants, doctors, etc.)
General Questions: (Required for all)
☐ Yes ☐ No Are you claiming use of a home office? If yes, please include Home Office Deduction Worksheet
☐ Yes ☐ No Do you have depreciable assets? If yes, please provide a detailed depreciation schedule
The Schedule should include: (Prior year detail is preferred):
A. Asset Description D. Accumulated Depreciation
B. Date Placed in Service E. Method of Depreciation and Years
C. Cost
☐ Yes ☐ No Self Insured Health Insurance Deduction? If yes, how much did you pay? $_____________
Vehicle Information: Year/Make/Model: _________________________________ Date Placed in Service: ____________
Total miles driven: ____________ Business miles: ____________ Commuting miles: ____________
Income Questions: (Required if no P&L or Trial Balance Available)
☐ Yes ☐ No Do you know what your business is worth? Total Sale: $_____________
☐ Yes ☐ No Would you like to know? Other Income: $_____________
Cost of Goods Sold: (Required if no P&L or Trial Balance Available)
☐ Yes ☐ No Do you have employees other than yourself? Beginning Inventory: $_____________
☐ Yes ☐ No Do you use subcontractors? Purchases: $_____________
☐ Yes ☐ No Do you do your own payroll? Cost of Labor: $_____________
☐ Yes ☐ No Would you consider outsourcing payroll to us? Materials and Supplies: $_____________
Ending Inventory: $_____________
General Expenses: (Required if no P&L or Trial Balance Available)
Advertising: $_____________ Legal & Professional: $_____________ Taxes & Licenses: $_____________
Auto Expenses: $_____________ Office Expense: $_____________ Travel: $_____________
(Other than Mileage): $_____________ Wages to Self: $_____________ Meals (Client/Prospect): $_____________
Commissions: $_____________ Wages to Children: $_____________ Utilities: $_____________
Contract Labor: $_____________ Wages to Others: $_____________ Other (List Below): $_____________
Depletion: $_____________ Pension/Prof Sharing Plans: $_____________ a.) ________________: $_____________
Depreciation (Need Sched):$_____________ Rent or Lease: $_____________ b.) ________________: $_____________
Employee Ben Programs: $_____________ a.) Vehicles, Machinery $_____________ c.) ________________: $_____________
Insurance (NOT Health): $_____________ b.) Other: $_____________ d.) ________________: $_____________
Interest: $_____________ Repairs & Maintenance $_____________ e.) ________________: $_____________
a.) Mortgage: $_____________ Supplies: $_____________ f.) ________________: $_____________
b.) Other: $_____________ Taxes & Licenses: $_____________ g.) ________________: $_____________
Tax Client Home Office Deduction Info Intake Page 7 of 8
Note: Effective 2018, Home Office Deduction is available only to self-employed.
Fill out COMPLETELY or mark “N/A”. Please DO NOT leave blank
--OR--
General
Date home was first used for business: _______________________
Square Footage of Area Used for Home Business: _______________________
Total Square Footage of the Home: _______________________
Simplified Option
The IRS now allows an optional standard $5 per square foot deduction (maximum 300 square ft)
If you would like to choose this option rather than Standard Option, enter the necessary info below, otherwise, skip this
section and complete the Standard Option section below.
☐ Yes ☐ No I would like to use the “Simplified Option” to claim my Home Office Deduction
Total square feet claimed for Home Office (cannot exceed 300 sq ft): ____________________
See: https://www.irs.gov/businesses/small-businesses-self-employed/simplified-option-for-home-office-deduction for
further information regarding Home Office Deduction
Standard Option – Deduction Expenses Current Year
Casualty Losses: $_____________
Deductible Mortgage Interest: $_____________
Real Estate Taxes: $_____________
Insurance: $_____________
Rent: $_____________
Repairs and Maintenance: $_____________
Utilities: $_____________
Other: ________________ $_____________
Other: ________________ $_____________
Other: ________________ $_____________
Other: ________________ $_____________
Depreciation:
☐ Yes ☐ No Do you have depreciable assets?
If yes, describe: ______________________________________________________________________________________
Special Information for the Tax Preparer
☐ Yes ☐ No Is there something “Unique” that the preparer should pay special attention to or know?
If yes, describe: ______________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
TAX Client Schedule E info-One Page Per Property Intake Page 8 of 8
Fill out COMPLETELY or mark “N/A”. Please DO NOT leave blank. Use a separate worksheet for EACH property
General: (Required for all)
Property Description: __________________ ☐ Taxpayer ☐ Joint - Owner of Property
Address: ____________________________
City: ___________ State: _____ Zip: _______
General Questions:
1.☐ Yes – Check for Active Participant
2.☐ Yes – Check if property was used for personal use by you or your family for more than 14 days or 10% of the total rented days
If checked, enter the number of days for personal use: ____________
If checked, enter the number of days rented: ____________
Questions Related to Rental of Your Personal Dwelling (Airbnb, VRBO, etc.)
If only a portion of the dwelling is rented out:
1a. Enter number of rooms, OR square footage of area rented: _________________ ☐ Rooms ☐ Sq Ft (Check one)
1b. Enter total number of rooms OR total square footage of dwelling: _________________ ☐ Rooms ☐ Sq Ft (Check one)
2. Repairs/Supplies* related directly to area being rented (can deduct all): $ _____________
*Do NOT include these again in Repairs/Supplies below
3. Rent you paid (if you rent rather than own the dwelling you’re renting out): $_____________
Income: Current Year
Rents Received $ _____________
Royalties $ _____________
Property Expense: Current Year
Note: IF printed material is received from client which CLEARLY indicates all info needed, fill in address above, stack printed material
below this page and write “See next xx pages” in large print below.
Advertising $ _____________
Cleaning/Maintenance $ _____________
Commissions $ _____________
Insurance $ _____________
Legal and Other Professional $ _____________
Management Fees $ _____________
Qualified Mortgage Interest $ _____________
Other Interest $ _____________
Repairs $ _____________
Supplies $ _____________
Real Estate Taxes $ _____________
Other Taxes $ _____________
Utilities $ _____________
Other: $ _____________
______________ $ _____________
______________ $ _____________
______________ $ _____________
______________ $ _____________
Assets:
Existing Assets: Please provide a detailed depreciation schedule. The schedule should include: a) Asset Description b) Date Placed in
Service c) Cost d) Accumulated Depreciation e) Method of Depreciation and Years
Description: _______________________________ Date Placed in Service: _____________ Purchase Amount: $_____________
Description: _______________________________ Date Placed in Service: _____________ Purchase Amount: $_____________
Description: _______________________________ Date Placed in Service: _____________ Purchase Amount: $_____________
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Completed 7 January 2021

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