Tax Preparation Client Data Intake Form

Tax Preparation Client Data Intake Form

Hopedealers Worldwide/The ROCC Private Referrals sent to The Jalonus Group- All forms are secure, encrypted, and HIPPA compliant.
Filing Status

SingleHead of HouseholdMarried Filing SeparateMarried Filing JointQualifying Widower

Taxpayer Information
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Date of Birth

MonthDayYear
Date
SSN
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Drivers License Number and State (ex. GA-22077567)
Date Issued

MonthDayYear
Date
Date Expires

MonthDayYear
Date
Check All that Apply

I am totally or permanently disabledI am legally blindI am a full time studentMy spouse and I lived apart during the yearSomeone else can claim me as a dependent
Employment Status

Self-employed (1099)Employed (W2)Unemployed (1099-G)Self-employed (NO 1099)

Income documents:

	From Where?	Amount
W2's
W2
W2
1099
1099
1099
Other income form
Other income form
Other income form

Occupation
Monthly Job Income
EIN (TAX ID#) - (if applicable)
Monthly Business Income (if applicable)
If you own a business, what is the name of the business?
What is the nature of the business?
Do you have a business plan?

YesNo
Have you made a profit in the past or will you make a profit in the future?

YesNo
Do you depend on income from this business?

YesNo
Has your business turned a profit in 3 of the last 5 years?

YesNo
Do you have a separate bank account for your business?

YesNo
How do you keep track of your business expenses?
Do you have receipts to support your business expenses?

YesNo
Date Business Established:

MonthDayYear
Date
Is your business any of the following?

LLCSub-Chapter S CorpPartnershipC-CorpNon-ProfitOther

Vehicle Information
Did you use your personal vehicle for business?

YesNo
Total Annual MIleage
Make / Model/ Year of Vehicle
How much used for Business Mileage?
How much used for Personal Mileage?

Spouse Vehicle Information
Did you use your personal vehicle for business?

YesNo
Total Annual MIleage
Make / Model/ Year of Vehicle
How much used for Business Mileage?
How much used for Personal Mileage?

Dependents (skip if not applicable)

Enter your dependents here

	Name of Dependent	Social Security Number	Date of Birth	Relationship	Months lived in home
1
2
3
4
5
6

Does you, your spouse, and your dependents have health insurance within 12 months last year? If yes, who covers for it?

	Yes/No	Exchange/ Marketplace	Employer	Spouse Insurance	Medicare	Medicaid
Taxpayer
Spouse
Dependent 1
Dependent 2
Dependent 3
Dependent 4
Dependent 5
Dependent 6

Child Care Information (skip if not applicable)
Do you receive the Advance Child Tax Credit Monthly?

YesNo
If yes, then how much was received?
Do you have any expenses for child care?

YesNo
If yes, then Child Care Provider's Name:

First NameLast Name
Child Care Provider's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Child Care Provider's SSN/EIN:
Amount Paid to Child Care Provider

Last Year Refund Information
Did you receive a refund last year?

YesNo
Federal Refund Amount:
Spouse Federal Refund Amount(if applicable):
State Refund Amount:
Spouse State Refund Amount (if applicable):

Business Expenses/ Write Offs
ONLY FILL IN WHAT APPLIES TO YOU FOR THE CURRENT YEAR OF ANNUAL TOTALS IF YOU HAVE YOUR OWN SELF-EMPLOYED BUSINESS EITHER FULL- TIME

OR

ONLY FILL IN REGARDING WHATEVER YOU DO ON THE SIDE IN ADDITION TO A JOB. (remember to consider what you may have put as self-employment with the marketplace/healthcare.gov)

COST OF GOODS SOLD

	Amount
Beginning Inventory, then add purchases, then subtract ending inventory
Other expense

ADVERTISING (Office Biz or Home Biz)

	Amount
Help Wanted Ads (linked in, etc.)
Magazine advertising/newspaper/digital/radio, etc.
Social Media Fees or Ads
Marketing (promo items, gifts, give aways)
Branded Promo Items (pens, banners, etc.)
Mailchimp, etc.
Website Design and/or App Creation
Website Maintenance/ Tech
Graphic Design
Flyers/ Brochures/ Marketing Pieces/ Biz cards
Go Daddy (domains, etc.)
Other Advertising Expense
Other Advertising Expense
Other Advertising Expense
TOTAL ADVERTISING EXPENSE

AUTO EXPENSES (note: the higher of either the actual expenses OR the mileage at a rate of .56 cents per mile will be taken)

	Amount
Auto Repair
Vehicle purchase cost (if purchased this year)
Auto Insurance
Maintenance (ex. oil changes, brakes, etc.)
License Plate (car tags)
Gas and Oil
Parking Fees
Toll Road Fees
Vehicle Property Taxes
OR
.56 per mile from mileage listed above (vehicle 1)
.56 per mile from mileage listed above (vehicle 2)
TOTAL AUTO EXPENSE TAKEN

INSURANCE (not health)

	Amount
E & O / Liability
State Insuance
Rental Insurance
Other business insurance
Other expense
TOTAL INSURANCE EXPENSE

INTEREST

	Amount
Interest on Business Related Loans
Other interest expense
Other insterest expense

LEGAL AND PROFESSIONAL FEES

	Amount
Legal - Attorney Fees/ Court filing fees
Club Memberships (Rotary,Networking Meetings,Lions Club)
Professional Association Fees
Bookkeeping/Accounting Services
Consulting Fees
Tax Preparation
Other Membership or Professional Fees
Other Expense
Other Expense
TOTAL LEGAL AND PROFESSIONAL FEES EXPENSE

OFFICE EXPENSES (Office Biz or Home Biz)

	Amount
Postage/Shipping
Software (Microsoft/Quickbooks/AntiVirus,etc.)
Cloud Storage (Dropbox, iCloud, Google Drive,etc)
Video Conferencing (Zoom, etc.)
Office Supplies (printer paper, pens, folders, etc.)
Printing
Equipment (purchased computer,printer, etc)
Cleaning and Paper products supply (cleaner, toilet paper, hand soap)
Other office expense
Other Expense
Other Expense
TOTAL OFFICE EXPENSES

RENT/LEASE (rented office only- not home)

	Amount
Rent for Business Space (not home office)
Other rental for business (storage, etc.)
Other Expense
Other Expense

REPAIRS AND MAINTENANCE (rented office only)

	Amount
Repairs on business property (not car)
Other Expense
Other Expense
TOTAL REPAIRS AND MAINTENANCE ON RENTED OFFICE ESPENSE

SUPPLIES (Office Biz or Home Biz)

	Amount
Books used within a year
Professional Equipment
Furniture purchased
Other equipment purchased
Other Supplies
Other Expense
TOTAL SUPPLIES EXPENSE

TAXES AND LICENSES

	Amount
Employee taxes
City/County/ State Tax (ex. occupational tax, etc.)
Business Licenses
Corporate Fees (sec of state, etc.)
Other Taxes or License Expense
Other Expense
TOTAL TAXES AND LICENSE EXPENSE

TRAVEL AND MEAL EXPENSES

	Amount
Airfare, Car Rental, Lodging
Meals (while traveling)
Passport/Visa
Other travel or meal expense
Other Expense
TOTAL TRAVEL AND MEAL EXPENSES

UTILITIES FOR BUSINESS(rented office only)

	Amount
Landline Phone
Cell Phone
Alarm System/Security
Gas Heat
Internet
Electric
Water
Other Utility Office Expense
Other Expense
TOTAL OFFICE UTILITY EXPENSE

WAGES (that you paid out)

	Amount
Wages paid to your employees
Additional Hired Help or sub contract
Health Insurance for employees
Other Expense
TOTAL WAGES EXPENSE

OTHER EXPENSES

	Amount
Continuing Education/Training/Classes
Conferences
Cleaning/ Janitorial
Bank Fees
Work Clothing/Uniform
Other Expense
Other Expense
TOTAL OTHER EXPENSES

HEALTH INSURANCE

	Amount
Health Insurance Cost
Other Expense
Other Expense

HOME OFFICE EXPENSES

	Amount
Property taxes
Homeowners/Renter Insurance
Landscaping
HOA Dues
Alarm System / Monitoring Fees
Gas Utility
Electric
Internet
Cell Phone
Home Phone/Fax
Other Expense
Other Expense
Other Expense
TOTAL HOME OFFICE EXPENSES
Percentage Calculation
Square Footage of Home
Square Footage of Office Space

Total BUSINESS Expenses

Banking Information
Would you like your refund deposited in your bank account?

YesNo
Bank Name
Routing Number
Account Number

Acknowledgment & Signature
I confirmed that all information I entered here is accurate and true. I allow The Jalonus Group to capture my sensitive data like personal id, government id, social security number (SSN), and other information. By signing below, you acknowledge that you have read and understood your responsibilities and our responsibilities in doing this tax return.
Date Signed

MonthDayYear
Date
Taxpayer Signature

Clear
Date Signed

MonthDayYear
Date
Spouse Signature

Clear

Uploads
Upload your forms here (W2's, 1099's, 1099-G, 1095-A, or any other forms here)

Cancelof

Payment for Services
We are happy to continue to provide this service to you again this year with our community partner, The Jalonus Group, which is lower cost than anywhere else you can find so that your information is seamless with what we have for you at the marketplace on healthcare.gov.

The Jalonus Group provide professional tax preparation ranging from $300-$600 or more depending on the complexity of each case. HOWEVER...

BECAUSE YOU ARE A CLIENT OF HOPEDEALERS WORLDWIDE/ The ROCC, (likely through health insurance), the owner of The Jalonus Group, Jennifer, has agreed to provide tax preparation services for our clients for a very reduced amount of only $135 minimum (provided your case is not extremely complex and that you have filled all this information in the fields above correctly). This generously reduced fee INCLUDES the electronic filing fee that the IRS charges everyone. If you want Jennifer's fee to be deducted later from your refund, then the bank charges an additional $35. If you pay the invoice Jennifer emails you in advance, then there is no $35 bank fee.

Please do not hesitate to contact Nadine, Skanda, or Mary at Hopedealers/The ROCC with any questions at 770.224.6825.
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