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Secure Client Tax Intake Forms

All information submitted is encrypted and protected in accordance with IRS privacy standards 

Individual Form

For W-2 employees, families, students, and standard individual returns.

SECURE CLIENT TAX INTAKE FORM


SECTION 1: PERSONAL INFORMATION

Birthday
Month
Day
Year
Are you filing dependents?
Yes
No
Does the child's biological parents live with the child?
Yes
No
Do you receive any government assistance?
Marital Status:

Spouse Full Name, SSN, & DOB

Section 2: DEPENDENTS

For each dependent provide the following:

Relationship
Do they live with you more than 6 months?
Yes
No
Did they attend college in 2025?
Yes
No
Did you pay for childcare?
Yes
No

SECTION 3: INCOME INFORMATION

Please upload ALL income documents.

Income Types Received: (Check all that apply)

SECTION 4: BUSINESS INFORMATION (IF APPLICABLE)

Are you self-employed?
Yes
No

SECTION 5: HEALTH INSURANCE

Did you receive Form 1095-A from Marketplace?
Yes
No

SECTION 6: ADDITIONAL TAX QUESTIONS

Can someone else claim you as a dependent?
Yes
No
Did you receive unemployment in 2025?
Yes
No
Did you receive a 6-digit IRS Identity Protection PIN?
Yes
No
Did you receive a state tax refund in 2024?
Yes
No
Did you make estimated tax payments in 2025?
Yes
No
Did you contribute to an IRA or retirement account?
Yes
No
Did you buy or sell stocks or cryptocurrency?
Yes
No
Did you pay more than half the cost of maintaining your home?
Yes
No
Are you active duty military?
Yes
No

SECTION 7: DIRECT DEPOSIT

Type of Account
Checking
Savings

SECTION 8: CLIENT DECLARATION


I certify that the information provided is true and complete to the best of my knowledge. I understand that The Burgess Firm LLC will prepare my return based solely on information i provide.


I acknowledge that I am responsible for reviewing my completed tax return before signing and filing.


I understand that The Burgess Firm LLC is not responsible for penalties, interest, or additional taxes resulting from incomplete or inaccurate information provided by me.


I consent to the electronic preparation and filing of my tax return.

Date
Month
Day
Year
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Thank you for choosing The Burgess Firm LLC

The Burgess Firm

Location
274 W Depot Street
Angier, NC 27501
United States
Office
(984) 397-6555
(910) 651-0651
 
Burgesstaxservicesllc@gmail.com
Business Hours
Monday: 9am - 5pm
Tuesday: 9am - 5pm
Wednesday: 9am - 5pm
Thursday:  9am - 5pm
Friday:  9am - 5pm 

Saturdays are appointment 
ONLY

Sunday - CLOSED 
 
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