Insighters - Individual Intake Form

Client Information

Client

Full Name *

Date of Birth *

SSN *

Driver's License / Exp Date / Issued State

Occupation

Spouse

Spouse Name

Date of Birth

SSN

Driver's License / Exp Date / Issued State

Occupation

Contact Information

Home Address *

City *

State *

Zip *

Phone Number *

Cell Phone

Email Address *

Filing Status

Single

Married Filing Jointly

Married Filing Separated

Head of Household

Dependants

Name	SSN	Date of Birth	Relationship	Months in Home

Income Collected

Did you or your spouse collect any of the following? (check all that apply)

Income

Pension Income

Gambling Winnings

Business Income

Social Security

Unemployment

Other

Expenses Paid

Did you or your spouse pay any of the following? (check all that apply)

Educational Expense

Business Expense

Other

Certification & Signature

I certify that the above information is true and accurate and I give Insighter's, Inc., the authority to prepare my Federal/State Tax return for the tax year stated above.

Disclaimer: Please be advised a $45 preparation fee will be assessed for a processed tax return if the client decides not to allow our office to complete your tax return.

Client's Signature *

Draw your signature above

Date *

I agree to the terms stated above and certify all information is accurate. *

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