Client Intake Form

First Name

Last Name

Phone #

Cell Phone Carrier

Spouse Full Name

Spouse Date of Birth

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Filing Status

Single

Married Filing Separate

Married Filing Joint

Head of Household

Qualifying Widower

Age

Occupation

Social Security Number

Date of Birth

Are you a full-time student?

Are you totally and permanently disabled?

How many dependents?

Bank Name

Employment Status:

Are you contributing to 401k or other pretax account:

Please select what state return are you requesting?

Does your dependents have tuition expenses?

Do you have any expenses for child care?

Do you receive a federal tax last year?

General Expenses:

Place the amount

Are you a victim of identity theft?

Total Expenses Amount:

Acknowledgment Statement for Tax Services Form (Florida Law Compliance)

By printing your name below, you acknowledge that all information provided on this form is true, accurate, and complete to the best of your knowledge. You understand that this acknowledgment carries the same legal effect as a handwritten signature under Florida law, and it will be used as your official signature for tax-related purposes.

info@belairefinancial.com