Client Intake/Interview Form

You will need:

• Social security cards or ITIN letters for all persons on your tax return.

• Picture ID (such as valid, unexpired Driver's License or State ID) for you and your spouse & all adult dependents on your tax return.

• Birth Certificates for all minor dependents on your tax return.

Please complete all pages of this form. You are responsible for the information on your return. Please provide complete and accurate information.

If you have questions, please ask your IRS- certified return preparer.

What tax year are you filing? *

Part I - Your Personal Information (If you are filing a joint return, enter your names in the same order as last year's return)

First Name *

M.I. *

Last Name *

Best contact number *

Social Security Number *

Are you a U.S. citizen? *

Yes

No

2. Your spouse’s first name

M.I.

Last name

Social Security Number

Best contact number

Is your spouse a U.S. citizen?

Yes

No

3. Mailing address *

Apt#

City *

State *

Zip code *

4.Your Date of Birth *

5. Your job title *

6. Last year, were you:

a. Full-time student *

If you were a student, have you claimed the American Opportunity Tax Credit 4 times in the past?

b. Totally and permanently disabled *

c. Legally blind *

7. Your spouse’s Date of Birth

8. Your spouse’s job title

9. Last year, was your spouse:

a. Full- time student

If your spouse was a student, have they claimed the American Opportunity Tax Credit 4 times in the past?

b. Totally and permanently disabled ?

c. legally blind ?

10. Can anyone claim you or your spouse as a dependent? *

11. Have you, your spouse, or dependents been a victim of tax related identity theft or been issued an Identity Protection PIN?

Yes

No

Who has a IP PIN & enter the PIN below

12. Provide an email address (this email address will not be used for contacts from the Internal Revenue Service) *

13. Provide an email address for your spouse (this email address will not be used for contacts from the Internal Revenue Service)

Part II – Marital Status and Household Information

1. As of December 31, 2022, what was your marital status?

Never married( This include registration domestic partnerships, civil unions, or other formal relationships under state law)

Married

Divorced

Legally Separated

Widowed

a. If Married, Did you get married in 2022?

Yes

No

b. Did you live with your spouse during any part of the last six months of 2022?

Yes

No

Date of final divorce decree (if applicable)

Date of separate maintenance decree (if applicable)

Year of spouse's death (if widowed)

Do you have any dependents? *

Yes

No

List the names below of:

-everyone who lived with you last year (other than your spouse)
-anyone you supported but did not live with you last year

Dependent 1

Full Name

Last Name

Social Security Number

Date of Birth (mm/dd/yyyy)

Relationship to You

If this person was listed as "Other", please list their relationship to you:

Was this person a U.S. Citizen?

How many months of the year did this person live with you in your home?

Was this person a Resident of U.S., Canada or Mexico last year?

Was this person under the age of 19 on the last day of the year?

Was this person Single or Married as of 12/31/2022?

Was this person a Full-time Student last year?

Was this person Permanently and Totally Disabled?

Did this person have less than $4,400 of income?

Could anyone else claim this person as a Dependent on their tax return?

Did you provide more than 50% of this person's support last year?

Did you pay more than half the cost of maintaining a home for this person?

Does this person have the same last name as you?

If you and this person have different last names, please explain why.

Do you have another dependent? *

Yes

No

Dependent 2

First Name:

Last Name

Dependent's Social Security Number:

Dependent's Date of Birth (mm/dd/yyyy)

Relationship to You

If this person was listed as "Other", please list their relationship to you:

Was this person a U.S. Citizen?

Yes

No

How many months of the year did this person live with you in your home?

Was this person a Resident of U.S., Canada or Mexico last year?

Was this person under the age of 19 on the last day of the year?

Was this person Single or Married as of 12/31/2022?

Was this person a Full-time Student last year?

Was this person Permanently and Totally Disabled?

Did this person have less than $4,400 of income?

Could anyone else claim this person as a Dependent on their tax return?

Did you provide more than 50% of this person's support last year?

Did you pay more than half the cost of maintaining a home for this person?

Does this person have the same last name as you?

If you and this person have different last names, please explain why.

Do you have another dependent?

Yes

No

Dependent 3

Full name ( First, Last Name )

Social Security Number

Date of Birth (mm/dd/yyyy)

Relationship to You

If this person was listed as "Other", please list their relationship to you:

Was this person a U.S. Citizen?

How many months of the year did this person live with you in your home?

Was this person a Resident of U.S., Canada or Mexico last year?

Was this person under the age of 19 on the last day of the year?

Was this person Single or Married as of 12/31/2022?

Was this person a Full-time Student last year?

Was this person Permanently and Totally Disabled?

Did this person have less than $4,400 of income?

Could anyone else claim this person as a Dependent on their tax return?

Did you provide more than 50% of this person's support last year?

Did you pay more than half the cost of maintaining a home for this person?

Does this person have the same last name as you?

If you and this person have different last names, please explain why.

Do you have another dependent? *

Yes

No

Dependent 4

Name (First, Last)

Last name

Social Security Number

Date of Birth (mm/dd/yyyy)

Relationship to You

If this person was listed as "Other", please list their relationship to you:

Was this person a U.S. Citizen?

How many months of the year did this person live with you in your home?

Was this person a Resident of U.S., Canada or Mexico last year?

Was this person under the age of 19 on the last day of the year?

Was this person Single or Married as of 12/31/2022?

Was this person a Full-time Student last year?

Was this person Permanently and Totally Disabled?

Did this person have less than $4,400 of income?

Could anyone else claim this person as a Dependent on their tax return?

Did you provide more than 50% of this person's support last year?

Did you pay more than half the cost of maintaining a home for this person?

Does this person have the same last name as you?

If you and this person have different last names, please explain why.

Do you have another dependent? *

Yes

No

Dependent 5

Name (First, Last)

Last Name

Social Security Number

Date of Birth (mm/dd/yyyy)

Relationship to You

If this person was listed as "Other", please list their relationship to you:

Was this person a U.S. Citizen?

How many months of the year did this person live with you in your home?

Was this person a Resident of U.S., Canada or Mexico last year?

Was this person under the age of 19 on the last day of the year?

Was this person Single or Married as of 12/31/2022?

Was this person a Full-time Student last year?

Was this person Permanently and Totally Disabled?

Did this person have less than $4,400 of income?

Could anyone else claim this person as a Dependent on their tax return?

Did you provide more than 50% of this person's support last year?

Did you pay more than half the cost of maintaining a home for this person?

Does this person have the same last name as you?

If you and this person have different last names, please explain why.

Privacy Act and Paperwork Reduction Act Notice

Federal Disclosure:

Federal law requires this consent form be provided to you. Unless authorized by law, we cannot disclose your tax return information to third parties for purposes other than the preparation and filing of your tax return without your consent. If you consent to the disclosure of your tax return information, Federal law may not protect your tax return information from further use or distribution. You are not required to complete this form to engage our tax return preparation services. If we obtain your signature on this form by conditioning our tax return preparation services on your consent, your consent will not be valid. If you agree to the disclosure of your tax return information, your consent is valid for the amount of time that you specify. If you do not specify the duration of your consent, your consent is valid for one year from the date of signature.

Primary taxpayer printed name and signature *

Date *

Secondary taxpayer printed name and signature

Date

Office: P.O. Box 2530 Southfield, MI 48037

Call: (313) 631-1024

Email: info@diamondreynoldscpa.com

Site: www.diamondreynoldscpa.com

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