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Intake Form

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Personal Information

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You’re filing status
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In case your contact information changes; we can contact you regarding your refund.

YesNo
Did you live at your above listed address 6 months or more?
Did you file your taxes last year?
If so, did you receive a refund?
How did you file your taxes last year, Self-Employment or W-2?
Can you get a copy of your prior years return if needed?
Do you need to file FORM 8862 (stating that you were disallowed EIC previously)?
Did you have health insurance ?
Dependent Information
First Name
Middle Name
Last Name
Birth Date
Social Security Number
Relationship To You
 
(If you have any dependents, list them in the area below. If you have more than four dependents, list the remainder on the reverse side. If any if your dependents did not live with you in 2016, please notify your preparer.)
YesNo
Did all of your dependents stay with you at least 6 months?
Did you file these same dependents last year?
Child Care Provider​
Child Care Provider
Address
City/ State/ Zip
 
SOCIAL SECURITY # OR FED ID NUMBER
Amount Paid
 
YesNo
Did you receive unemployment income?
Did you attend college, night school, internet schooling, or any post-secondary educational facility to gain a skill or degree?
Do you have a 1098-T form from your school?
Are you currently paying or owe student loans?
Do you own your home?
Do you owe for home buyers credits?
Did you pay church tithes and offerings?
Do you owe back child support?
Do you owe the IRS?
How would you like your IRS refund issues?

ALTERNATE ELIGIBILTY RECORD (Due Diligence)

In accordance with Internal Revenue Service (IRS) Bulletin 97-65 and Internal Revenue Code (IRC), this form serves as Alternate Eligibility Checklist, and may be used IN LIEU of other forms of Due Diligence, including form 8867. Maintain this form with your client files.

HEAD OF HOUSEDHOLD ELIGIBILITY

You may file Head of Household if you can answer YES to ALL the following questions. (See Publication 17, Chpt 2&3)
YesNo
You are unmarried, or are considered unmarried on the last day of the year.
You paid more than half the cost of keeping up a home for the year.
A qualifying person (definition below) lived with you in the home for more than half the year (except temporary absences, such as school), and you can claim an exemption for him/her except as noted under Category 3 below.

A qualifying person requirements are: (See Table 2-1, Publication 17)

A qualifying relative such as parent, grandparent, brother, sister, stepbrother, stepsister, stepmother, stepfather, father-in-law, half-brother, half-sister, brother-in-law, sister-in-law, daughter-in-law, uncle, aunt, nephew, or niece who is related to you by blood and lived with you for the entire year. Child, grandchild, stepchild, or adopted child. Eligible foster child. (Note: For eligibility for dependent only a foster child is a child who is in your care, that you care for as your own child, and who lived with you the entire year. It does not matter how the child became a member of the household)

EARNED INCOME CREDIT (EIC) ELIGIBILTY

You may claim the EIC if you can answer YES to ALL 4 tests below. (See publication 17, Chapter 36)
YesNo
Your child/ children is/are one of the following: a son, daughter, adopted child, stepchild, grandchild, or eligible foster child or is your brother, sister, stepbrother, stepsister (or the child or grandchild of your brother, sister, stepbrother, or stepsister), and you care for it/them as you would your own child.
Your child/children is/are under 19 years of age at the end of the year, or is under 24 years of age at the end of the year and is a full-time student, or was permanently and totally disabled at any time during the tax year, regardless of age.
Your child/ children lived with you for more than half the year (or the whole year if an eligible foster child)
Your home is in the United States
If your child/ children is/are the qualifying child/ children of another individual, you are the only person claiming the credit for that/ those child/children during the tax year. (Note: If the answer is NO, refer to the tiebreaker rule. You may still be able to take the credit.

FOSTER CHILD ELIGIBILTY

The definition of a foster child has changed. For establishing eligibility for dependency, see above. For establishing eligibility for the Child Tax Credit and Earned Income Credit you must be able to answer YES to ALL the questions below.
YesNo
You cared for the child/ children as you would your own child.
The child/ children lived with you for the entire year, except for temporary absences.
The child/ children was/ were placed in your care by a State, one of its subdivision, or placement agency.

Self-Employment Form

Real Estate & Equipment Purchased
Description
Date
Cost
 
Did you work a job & do anything to make extra money on the side?

Everything I am signing is true to the best of my knowledge

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