Client Intake Questionnaire Web Site Martin O. Stubbs M.P.A. Client Intake Questionnaire Hello, and thank you for taking a moment to submit your information. We look forward to serving your tax needs! This is secure, confidential information that will not be shared with any parties outside of Stubbs Tax and Financial Services. Please complete as much information as possible. If you require a paper version of this form, please call our office at 904-278-0117. Your Information First Name * Last Name * Phone * Alternate Phone Email Address * Street Address * City * State * Zip Code * Date of Birth * Driver's License # * License Issue State * License Issue Date * License Expire Date * Social Security # This is a secure, encrypted form. We will need your SS# at some point to get started. Bank Name This is for IRS Electronic Refunds Routing Number 9-digit # on your checks. Account Number The unique # (usually on the bottom right) on your checks. Occupation * Referred By Marital Filing Status (Only check one) * Filing Single Filing Married (Joint) Spouse Information Leave blank if single. First Name Last Name Date of Birth Driver's License # License Issue State License Issue Date License Expire Date Social Security # This is a secure, encrypted form. We will need your SS# at some point to get started. Occupation A few tax questions Educational Expenses (if any) Are you filing on time this year? * Yes No Not Sure Can you submit tax documents electronically? * Yes No Not Sure Any major changes in your tax filing status? * Yes No Not Sure Deducting Dependents? (Only check one) * Yes No Dependents other than yourself. List all claimed defendants you will claim for tax deductions. If you have more than three, enter the information in the comments section below. Dependent #1 Name Name as it appears on their Social Security card Dependent #1 SS Dependent #1 Date of Birth Dependent #2 Name Name as it appears on their Social Security card Dependent #2 SS Dependent #2 DOB Dependent #3 Name Name as it appears on their Social Security card Dependent #3 SS Dependent #3 DOB Questions or comments? Feel free to ask a question or simply leave a comments below. Comments / Questions Signed * Type your name as an electronic signature. Date 1 * Signed 2 Type your name as an electronic signature. Date 2 Service Agreement Full payment is due upon completion of services. Appointment of the service of Martin Stubbs Tax and Financial Planning Services of Orange Park, Florida signifies consent to pay all fees and any additional fees associated with the collection of unpaid fees. Thank you! You will be receiving an email confirmation from us once we receive this.