OBA Tax and Consulting Services

2021 Client Intake Form

(352) 290-2830

Have you been assigned a OBA Tax and Consulting Services Tax Professional?

Yes

Select Team Member

Were you referred to Luxury Tax Services? Please let us know who to thank!

Referred by: *

Today’s Date: *

Client’s Full Legal Name: *

Client's Social Security Number: *

Spouse’s Full Legal Name:

Spouse's Social Security Number

Spouse’s Date of Birth:

Current Address (please include zip code) *

Current Home Phone Number:

Current Cell Phone Number: *

Spouse’s Cell Phone Number:

Email Address: *

Spouse’s Email Address:

Current Occupation: *

Your Spouse’s Current Occupation:

Have you been a victim of identity theft and been given an identity theft protection PIN by the IRS? If yes, enter the six digit identity protection PIN number. *

Has the spouse been a victim of identity theft and been given an identity theft protection PIN by the IRS? If yes, enter the six digit identity protection PIN number.

Were you, your spouse, or any of your dependents Enrolled at least part time in an accredited College, Trade School or University in 2021? *

Name of accredited College, Trade School or University? *

How many years of school have been completed prior to December 31, 2021? *

Were you, your spouse, or any of your dependents who were enrolled at least part time in an accredited College, Trade School or University issued a 1098T or 1098E form? *

What county did you live and work in as of December 31, 2021?

What SCHOOL DISTRICT did you live in as of December 31, 2021?

Did you file your 2020 Tax Return? *

Did you receive your expected refund? *

Have you ever had EARNED INCOME CREDIT DISALLOWED by the IRS? *

Was your tax return completely offset last year? *

Will you be filing more than one STATE return? If so, WHICH STATE? (2021)

Did you receive a PPP loan? If so, for how much? Was it forgiven? And if so, what was the amount? *

DEPENDENT INFORMATION

Are you claiming any dependents that you provided MORE THAN HALF the support for? *

If yes, fill out their information below:

Dependent #1

Full Legal Name:

Relationship to Taxpayer:

Social Security Number:

Date of Birth:

Full Legal Name(s) of Biological Parent(s):

How long did the dependent live in your home during the tax year?

Dependent #2

Full Legal Name:

Relationship to Taxpayer:

Social Security Number:

Date of Birth:

Full Legal Name(s) of Biological Parent(s):

How long did the dependent live in your home during the tax year?

Dependent #3

Full Legal Name:

Relationship to Taxpayer:

Social Security Number:

Date of Birth:

Full Legal Name(s) of Biological Parent(s):

How long did the dependent live in your home during the tax year?

Do you have additional dependents? Add them below.

Dependent #4

Full Legal Name:

Relationship To Taxpayer:

Social Security Number:

Date Of Birth:

Full Legal Name(S) Of Biological Parent(S):

How Long Did The Dependent Live In Your Home During The Tax Year?

Dependent #5

Full Legal Name:

Relationship To Taxpayer:

Social Security Number:

Date Of Birth:

Full Legal Name(S) Of Biological Parent(S):

How Long Did The Dependent Live In Your Home During The Tax Year?

Dependent #6

Full Legal Name:

Relationship To Taxpayer:

Social Security Number:

Date Of Birth:

Full Legal Name(S) Of Biological Parent(S):

How Long Did The Dependent Live In Your Home During The Tax Year?

Dependent #7

Full Legal Name:

Relationship To Taxpayer:

Social Security Number:

Date Of Birth:

Full Legal Name(S) Of Biological Parent(S):

How Long Did The Dependent Live In Your Home During The Tax Year?

Do you have joint custody of the above listed DEPENDENT(S)? *

Did you receive your Stimulus Payment? If so, how much? *

Did you receive the Advance Child Tax Credit? If so, how much? *

Do you have a signed IRS Form 8332? *

Per IRS new guidelines, please indicate where the dependent’s Non-Custodial parent/parents are and why they will not be filing this dependent? *

Will you claim the CHILD CARE DEDUCTION for this tax year? If so, full legal name, social security (tax ID), address and amount per child paid: *

Do you receive ANY supplemental, nontaxable income such as child support, Food stamps, Medicaid/ Medicare, TANF, social security, or disability if so, how much? (Please list each type that applies along with the amount) *

Have you traded, engaged in any stocks or any crypto currency (for example: Coinbase, Robinhood, Cashapp, etc? *

REAL ESTATE AND VEHICLE

Are you a homeowner? Did you purchase your first home in 2021?

If YES - the questions below are REQUIRED.

Enter amount of the home/property - IF YES:

Did you pay real estate taxes in 2021? IF YES enter AMOUNT:

Did you pay Property Taxes for your home in 2021? Enter amount IF YES:

Did you pay Mortgage Interest for your home in 2021? Enter amount IF YES:

Did you make any ENERGY IMPROVEMENTS to your MAIN HOME in 2021? IF YES enter AMOUNT:

Did you pay upkeep and repair expenses for your home in 2021? If Yes enter AMOUNT:

Did you pay for Property Insurance for your home in 2021? IF YES enter AMOUNT:

Did you RENT? IF YES, how many months and the AMOUNT paid in 2021:

Did you pay renters insurance? AMOUNT paid in 2021:

Did you purchase a NEW VEHICLE after February 16, 2021? IF YES enter AMOUNT:

Amount, IF any personal property taxes:

Amount of any significant MEDICAL/DENTAL expenses:

Amount IF any cash- noncash contributions to charity in 2021:

Amount IF any rental income property in 2021?

DISABLED

Are you, your spouse, or any dependent listed on your tax return disabled? *

If YES - the questions below are REQUIRED

What is the nature of the disability?

Has this dependent been declared disabled by a physician? If so, can you provide documentation?

Are you or your spouse listed as the Social Security Representative Payee for this dependent?

Is this the dependent(s) expected to recover in the next year?

Will you claim the DEPENDENT CARE DEDUCTION for the disabled dependent If so, full legal name, social security (tax ID), address and amount per disabled dependent paid:

Did you pay out of pocket for any uncovered Medical Expenses for the disabled dependent, if so, enter the amount for the year?

Please sign below - spouse signature if appropriate.

Taxpayers Signature *

Clear

Taxpayers Spouse’s Signature

Clear

Date *

DIRECT DEPOSIT

IF YOU WOULD LIKE DIRECT DEPOSIT: PLEASE BRING A VOIDED CHECK TO AVOID ERRORS:

Name of Bank: *

Account Number: *

Routing Number: *

Signature of Taxpayer *

Clear

Date *

Signature of Tax Preparer

Clear

Date

REFERRAL

We continue to grow our business through loyal customers like you. Please look in your cell phones and provide us with at least 3 names and phone numbers of people needing assistance in preparing their taxes and getting back the maximum amount of money they are legally entitled as such it is imperative to us that you leave at least 1 referral:

Name of whom you are referring?

What is their phone number?

#2 Name of whom you are referring?

#2 What is their phone number?

#3 Name of whom you are referring?

#3 What is their phone number?

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.