JFS Client Intake/ Interview Form - Jefferson Financial Services
JFS Client Intake/ Interview Form
New Client
Yes
No
You will need: Income reporting forms: W2, 1099, 1095, etc. Social Security cards/ ITIN letters for all persons on your tax return Valid picture ID (State issued) for both Taxpayer and Spouse
PART I YOUR PERSONAL INFORMATION
Taxpayer Information Last Name
MI
First Name
Date:
Appointment:
Please complete all pages of this form You are responsible for the information on your tax return Please provide complete and accurate information Be sure to sign the bottom of the 3rd page
Spouse Information Last Name
MI First Name
SSN/ ITIN
Date of Birth
SSN/ ITIN
Date of Birth
Job Title
Phone Number
Job Title
Phone Number
Street Address
Apt.
Street Address
Apt.
City
State Zip Code
City
State Zip Code
Driver's License/ ID
State Exp. Date
Driver's License/ ID
State Exp. Date
DL/ID Issue Date
Email Address
DL/ID Issue Date
Email Address
If you are completing a prior year tax return please answer the questions for that filing year Can anyone claim you as a dependent on their tax return? Yes No
If you are completing a prior year tax return please answer the questions for that filing year Can anyone claim you as a dependent on their tax return? Yes No
As of 12/31/2020 were you
Last year were you:
Yes
No
A Full-time student
Permanently Disabled
A victim of identity theft
PART II FILING STATUS (SELECT ONE)
Unmarried
Married
Widowed
Did you adopt a
Last year were you:
Yes
child last year? A Full-time student
Yes
No
Permanently Disabled
Pin #
A victim of identity theft
No
Did you adopt a
child last year?
Yes
No
Pin #
If so select your filing status:
Did you live with your spouse any part of the last 6 months of 2020?
Single
Yes
Would you like to
file:
Head of Household
Married
Married Filing Separate
Date of spouse's death: Mo: ____________ Day: ___________ Yr. _____________
No. of months lived in home with taxpayer(s) Full-time College Student Totally & Permanentl y Disabled
PART III HEALTHCARE
Health Care Coverage: Please check the box under the members of your family that had Health Coverage in 2020
Taxpayer Spouse. Dependents Did you receive form 1095-A?
Yes
No
Dependent Information
Name (Last, First, Middle Initial)
SSN
Relationship
DOB
Please answer the questions (Y) for Yes (N) for No
Did you provide > 50 of support for this person
Is this person a qualifying child of any other person
Did the taxpayer pay more than ? the cost of maintaining the home for this person
Did you receive a stimulus check?
Yes
No If so, how much? _______________________________
Childcare Expenses Child Provider Address City/State Phone
Tax ID/SSN
Zip Code Total paid
Child Provider Address City/State Phone
Tax ID/SSN
Zip Code Total Paid
College or Post-Secondary Education Expenses
Student
Name of School
School Expenses $ _____________________
Please provide proof of expenses
Address City/State
Student School Expenses $ _____________________
Name of School Please provide proof of expenses
Address City/State
Student
Name of School
School Expenses $ _____________________
Please provide proof of expenses
Direct Deposit/ Fees/ Signature
Bank Routing Number
Direct Deposit: YES NO
Name of Bank
Address City/State
Account Number
Checking
Savings
Income Tax preparation fees are due today. Select your method of payment: Select how you would like to file your income tax return E-file
Cash
Credit/Debit
If you are new to JFS how did you hear about us?
Who referred you? Client Referral? ____________________________________
Other: ___________________
Authorization
I authorize JFS to prepare and process my income taxes. All of the information has been provided by me and is accurate to the best of my knowledge. I have been given the opportunity to review my tax return before it is filed
Taxpayers Signature________________________________________________ Date_________________ Office Use Only Intake ______ Preparer _______
................
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