Client Intake Form

IMPORTANT: UPON COMPLETION OF ALL APPLICABLE PARTS OF THIS FORM YOU MUST CLICK THE "SUBMIT" BUTTON AT THE BOTTOM OF THE FORM TO SEND THIS INFO TO OUR OFFICE. CLOSING YOUR BROWSER BEFORE CLICKING THE "SUBMIT" BUTTON WILL DELETE ALL INFO WITHOUT SENDING TO US. IT SHOULD BE NOTED THAT UPON CLICKING THE SUBMIT BUTTON YOU WILL GET A CONFIRMATION EMAIL THAT WE RECEIVED YOUR INFO.

Please also note that to comply with federal and state identity theft protection efforts our firm will ask for a valid state issued photo identification card during your engagement.

***The page is highly secure. We use industry-leading technology Secured Socket Layer (SSL) to keep your information safe. All sensitive information are securely transmitted and can not be compromised.

This questionnaire has been divided into sections and may take you up to 30 minutes to complete. Organize all your tax documents and save yourself the hassle of having to come to our location to get your taxes done.

Will you be filing your tax return with your Spouse? *

Yes

No

Spouse's Full Name

Spouse's Date of Birth

Spouse's Social Security Number

Spouse's Current Address

Current City

Current State

Current Zip Code

Spouse's Email Address

Spouse's Mobile Number

Spouse's Social Security Card

Spouse's Photo Identification

Did your spouse work?

Yes

No

Spouse's Income Documents (W-2, 1099 etc)

Was your Spouse issued an Identity Protection PIN (IP PIN) by the IRS?

Yes

No

Dependent #1 Full Name

Dependent Date of Birth

Dependent Social Security Number

Dependent #1 Relationship

Dependent #2 Full Name

Dependent #2 Date of Birth

Dependent #2 Social Security Number

Dependent #2 Relationship

Dependent #3 Full Name

Dependent #3 Date of Birth

Dependent #3 Social Security Number

Dependent #3 Relationship

Dependent #4 Full Name

Dependent #4 Date of Birth

Dependent #4 Social Security Number

Dependent #4 Relationship

Dependent #5 Full Name

Dependent #5 Date of Birth

Dependent #5 Social Security Number

Dependent #5 Relationship

Dependent #6 Full Name

Dependent #6 Date of Birth

Dependent #6 Social Security Number

Dependent #6 Relationship

Dependent #7 Full Name

Dependent #7 Date of Birth

Dependent #7 Social Security Number

Dependent #7 Relationship

Dependent Social Security

Please upload a copy of the dependents social security cards OR other document that has SSN on it. (Please take clear pics. If you were a last year client and filing the SAME dependent, you do not need to upload anything.)

Did you or your family have health insurance at any time in 2021 FROM THE MARKETPLACE? HEALTHCARE.GOV * *

Yes

No

1095A

Upload 1095A Please be sure to take clear pictures of the form.

Would you like to apply for the advance up to $6000? (It all depends on the amount of your refund) Also Republic Bank is does something different. Instead of denying some people they are counter offering an advance for a lower amount. If this does happens I just want you to know your refund will still go into the place you requested initially. Amounts are:

$6000 - $189.36 fee Refund must be at least $7000

$4500 - $142.02 fee Refund must be at least $5500

$3000 - $94.68 fee Refund must be at least $4000

$2000 - $63.12 fee Refund must be at least $3000

$1500 - $47.34 fee Refund must be at least $2000

$1000 - $31.56 fee Refund must be at least $2000

$500 - $15.78 fee Refund must be at least $500

How would you like your refund? *

Would you like to receive a text message when your refund is funded?

Bank Name *

Account Number *

Routing Number *

ENGAGEMENT LETTER AND CONSENT FORM SECTION

CLIENT ENGAGEMENT LETTER

SIGN IN BOX BELOW WITH YOUR MOUSE OR A STYLUS IF USING A TOUCHSCREEN ENABLED DEVICE

Please sign indicating agreement with the above engagement letter

Signature *

Clear

CONSENT TO USE OF TAX RETURN INFORMATION

SIGN IN BOX BELOW WITH YOUR MOUSE OR A STYLUS IF USING A TOUCHSCREEN ENABLED DEVICE

Please sign to indicate you give consent as spelled out above

Consent Signature *

Clear

CONSENT FOR PAYMENT FORM

SIGN IN BOX BELOW WITH YOUR MOUSE OR A STYLUS IF USING A TOUCHSCREEN ENABLED DEVICE

Please sign to indicate you give consent as spelled out above

Signature * *

Clear

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

Captcha

We believe that the best way to grow our business is through personal recommendations from satisfied clients like yourself. That's why we're inviting you to participate in our referral program and help us connect with up to five new clients in your network.

Refer up to five friends, family members, colleagues, or acquaintances by listing their name, email address & phone number below!

Referral 1.
Referral 2.
Referral 3.
Referral 4.
Referral 5.

Office:

950 28th ST SE Suite 104 Building E Grand Rapids, MI 49508

Call
866-945-4828

Email:

wecare@moneymattersfs.com

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