Client Intake Form

Part 1: Your Personal Information

Part 2: Dependent Information

Part 3: EITC Questionnaire

Please answer the following questions accordingly.

Question	Yes	No
Has correct identification been provided?
Do all names on return match SS cards provided?
By your state's definition, are you LEGALLY married?
If yes, did your spouse live in your home through July or until December?
Did you/spouse receive military pay?
Can anyone claim you/spouse as a dependent?
Did you/spouse live with someone with a higher adjusted gross income?
Are you renting a room and can provide a rental agreement?
Do you have a Dependent/Qualifying Child?
Have you verified birthday information entered on the return?
Did you/spouse provide over 50% of total support per ea. Dependent?
Does your dependent have a valid SS#?
-Under 19 and lived in the taxpayer's home more than one-half of the year?
-Under 19 and foster child of the taxpayer and lived in the home for a full year?
-Under 19 and younger than you or your spouse?
-Full-time student age 19-24?
-Disabled and can you provide proof?
*Are you claiming a brother, sister, niece, nephew, grandchild, or parent?
Did the parents of the dependent also live in the household?

* Every cell is required.

Please respond according to the previous question.

Question	Answer Here
- If no, what is the reason for the absence?
- If yes, did they financially contribute to the household?
- If yes, is your adjusted gross income higher than that of the parents?
How many months have the dependent lived in your household?
Can anyone else claim this dependent? Y/N

Part 4: Self Employment

Part 5: Bank Information

Part 6: Additional Information