Tax Client Intake Form

Thank you for choosing DISPA Distribution LLC for your tax filing needs! We’re excited to serve you. Please complete the intake form as thoroughly as possible. If you have any questions or need assistance, feel free to call us at +1 754-234-5337.

Tax Payer Information

First Name *

Last Name *

Phone *

Email *

Address

Home Address *

City *

State *

Country *

Postal Code *

Do you have an IRS Identity Protection PIN (IP PIN)? *

Yes

No

Enter your 2025 Identity Protection PIN below: *

Social Security Number *

Picture of Social Security Card (SSN) *

Picture of Social Security Card (SSN)

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF ( max 10 Files )

Picture of ID Card/License (one) *

Picture of ID Card/License (one)

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF ( max 10 Files )

Tax Documents (W-2 Forms, 1095-A forms etc) *

Tax Documents (W-2 Forms, 1095-A forms etc)

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF ( max 10 Files )

Filing Status *

Single

Head of Household (Single with Dependents)

Married Filing Joint

Married Filing Separate

Spouse Information

Spouse First Name *

Spouse Last Name *

Spouse Date Of Birth *

Spouse Phone Number *

Spouse Email *

Spouse Address *

Street Address Line 2 *

City *

State Province *

Postal / Zip Code *

Spouse Occupation *

Spouse Social Security Number *

Upload Spouse Social Security Card *

Upload Spouse Social Security Card

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF ( max 10 Files )

Upload Picture of ID Card/License

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF ( max 10 Files )

Are You Claiming Dependents? *

Yes

No

Information of Dependents

Dependant 1

Dependant 1 - Name (as it appears on Social Security Card) *

Dependant 1 - Date Of Birth *

Dependant 1 - Birth Certificate

Birth Certificate

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF ( max 10 Files )

Dependant 1 - Social Security Card or ITIN *

Social Security Card or ITIN of dependant person

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF ( max 10 Files )

Dependant 1 - Relationship *

Dependant 2

Dependant 2 - Name (as it appears on Social Security Card)

Dependant 2 - Date Of Birth

Dependant 2 - Birth Certificate

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF ( max 10 Files )

Dependant 2 - Social Security Card or ITIN

Social Security Card or ITIN of dependant person

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF ( max 10 Files )

Dependant 2 - Relationship

Dependant 3

Dependant 3 - Name (as it appears on Social Security Card)

Dependant 3 - Date Of Birth

Dependant 3 - Birth Certificate

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF ( max 10 Files )

Dependant 3 - Social Security Card or ITIN

Social Security Card or ITIN of dependant person

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF ( max 10 Files )

Dependant 3 - Relationship

Dependant 4

Dependant 4 - Name (as it appears on Social Security Card)

Dependant 4 - Date Of Birth

Dependant 4 - Birth Certificate

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF ( max 10 Files )

Dependant 4 - Social Security Card or ITIN

Social Security Card or ITIN of dependant person

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF ( max 10 Files )

Dependant 4 - Relationship

Bank Information

Bank Name *

Routing Number *

Account Number *

Account Type *

Checking

Savings

Void Check

Void Check.

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF ( max 10 Files )

Upload Any Additional Documents

Please Upload Any Additional Documents

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF ( max 10 Files )

DISPA Distribution LLC will use the information you provide to prepare your 2025 individual tax return. As the taxpayer, you are solely responsible for the accuracy and filing of your tax return.

I, the taxpayer listed above, confirm that I have provided DISPA Distribution LLC with all required tax information, and to the best of my knowledge, the information submitted is true, accurate, and complete.

Tax Payer Signature *

Clear

Spouse Signature

Clear

Date Signed *

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Tax Client Intake Form

Tax Payer Information

Spouse Information

Information of Dependents

Dependant 1

Dependant 2

Dependant 3

Dependant 4

Bank Information

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