Client Intake

Over 21 years of experience. We are filling in all 50 states.

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When you refer anyone, we will pay you up to $150 per referral on the same day.

Are you?

Please Select

How did you hear about us?

Please Select

Referral: Who Referred you to us?

What kind of appointment would you like?

Please Select

Please enter your contact information

Prefix

First Name

Middle Name

Last Name

Date of birth

Social Security Number

Occupation

Address

Street Address

Phone

Please enter a valid phone number.

Email *

[email protected]

Prefix(2)

Spouse First Name

Middle

Spouse Last Name

Spouse Date Of Birth

Spouse Occupation

Spouse Address

Street Address

Street Address Line 2

Spouse City

State/Province

Postal/Zip Code

Select your filing status

Single

Married Filing Jointly

Married Filing Separately

Head of Household

Qualifying Widow(er)

Other

Select all applicable income sources

Employment (Wages/Salary))

Self Employment

Investments (Dividends/Interests))

Rental Income

Retirement Pension

Unemployment Benefits

Other

Upload W2 Form

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Upload Picture of Your ID

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Additional Tax Forms

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Supporting Documents (Such as: Lease, Utility Bills, Birth Certificate, Custody order, School, Medical and Daycare)

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

What State do you live in?

Do you have an IRS account, www.IRS.gov ? If not please create one

⁠How many tax years do you need to file?

Have your refund ever been reduced or denied in a prior year? Which year?

Last year or early this year did you receive any letters in the mail from the IRS or the State?

Do you owe debt to any Government Agency; such as IRS, Student Loans, Child Support etc? Explain.

1. Would you like to join our Credit Repair Program and start the new year with a 800 credit score?

Yes

No

2. Did you receive a refund last year?

Yes

No

3. Can another taxpayer claim you as a dependent on their tax return?

Yes

No

4. Will you be filing a tax return with your spouse?

Yes

No

5. Do you have any dependents other than your spouse you will be claiming on your taxes?

Yes

No

6. Did you, your spouse or any dependents attend college in 2025?

Yes

No

7. Did you receive health insurance through the Market Place?

Yes

No

8. Did you or your spouse receive unemployment benefits in 2025?

Yes

No

9. If you own your home, have you received form 1098 from your mortgage lender?

Yes

No

10. form 1098 from your mortgage lender? * Yes No Are you self employed?

Yes

No

11. Are you interested in the SAME DAY Advance up to $9,500 with bank approval?

Yes

No

12. Did you or your spouse make payments on your student loans in 2025?

Yes

No

13. Did you receive the marketplace insurance?

Yes

No

14. Did you receive unemployment benefits in 2025?

Yes

No

ROEBUCK Tax