2022 Income Tax Intake Form Verified Previous Full SubmissionAre you only uploading documents?*Yes, I am just uploading documents to go with the form I have already submittedNo, I am completing the form for the first time.Primary Taxpayer InformationPlease Note that you can "Save and Continue" this form later by using the link at the bottom of the page next to the "Submit" button. Primary Taxpayer Name* Dr.MissMr.Mrs.Ms.Prof.Rev. Prefix First Middle Last Suffix Email* Enter Email Confirm Email Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920SS#*Driver's License # or Official ID #*ID Issue Date* MM DD YYYY ID Expiration Date* MM DD YYYY Occupation*Passcode*Please set a 4-6 digit passcode that we can use to identify you. Please keep this passcode confidential. Please Answer the FollowingDid Chronicles of Numbers, LLC prepare your last return?*YesNoHow did you learn of Chronicles of Numbers, LLC?Where did you file your prior year return?*Has a copy of prior year return been provided to Chronicles of Numbers, LLC?*YesNoPlease upload a copy of last year's return Drop files here or Have you had any tax return issues in the past 3 years?*YesNoPlease Explain*Did you receive a stimulus payment in 2021?*YesNoIf you receive a refund, do you want to use direct deposit?*YesNo9-Digit Routing Number*Bank Account Number*Were you married on December 31st?*YesNoWere you living together in July?*YesNoSpouseSpouse's Name* Dr.MissMr.Mrs.Ms.Prof.Rev. Prefix First Middle Last Suffix Email* Enter Email Confirm Email Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920SS#*Driver's License or Official ID*ID Issue Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920ID Expiration Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Occupation*Personal InformationAddress* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Spouse's Home PhoneYour Cell Phone*Spouse's Cell PhoneYour Work Phone*Spouse's Work PhoneHouseholdPlease list everyone living at your address, including yourself.*Please add one person per line. Press the "+" to add another line.First NameLast Name How many dependents are you claiming?*0123456789Dependent 1Name* First Last SS#*Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Does Dependent 1 attend daycare or before/after school care?*YesNoName of care provider / institution:*Is Dependent 1 a student? (elementary, middle, high school, college)?*YesNoSchool Name*Is Dependent 1 disabled?*Disabled is defined as they are on a disability program.YesNoOfficial Documentation for disabled dependents*You must provide official documentation PRIOR to electronically submitting a return. Examples of documentation may include, but not be limited to, the following: Disability Letter from Doctor (will be verified), Notice from Social Security Administration, Immobility Card with Photo ID, etc. Drop files here or Did the dependent reside with you for at least 6 months this past year?*YesNoDependent 1’s relationship to you*sondaughterbrothersisterstep childniecenephewgrandchildcourt-ordered foster childadopted childPlease upload Proof / Court Documents* Drop files here or Who are the Biological Parents?Biological Mother's Name* First Middle Last Biological Father's Name* First Middle Last Dependent 2Name* First Last SS#*Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Does Dependent 2 attend daycare or before/after school care?*YesNoName of care provider / institution:*Is Dependent 2 a student? (elementary, middle, high school, college)?*YesNoSchool Name*Is Dependent 2 disabled?*Disabled is defined as they are on a disability program.YesNoOfficial Documentation for disabled dependents*You must provide official documentation PRIOR to electronically submitting a return. Examples of documentation may include, but not be limited to, the following: Disability Letter from Doctor (will be verified), Notice from Social Security Administration, Immobility Card with Photo ID, etc. Drop files here or Did the dependent reside with you for at least 6 months this past year?*YesNoDependent 2’s relationship to you*sondaughterbrothersisterstep childniecenephewgrandchildcourt-ordered foster childadopted childPlease upload Proof / Court Documents* Drop files here or Who are the Biological Parents?Biological Mother's Name* First Middle Last Biological Father's Name* First Middle Last Dependent 3Name* First Last SS#*Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Does Dependent 3 attend daycare or before/after school care?*YesNoName of care provider / institution:*Is Dependent 3 a student? (elementary, middle, high school, college)?*YesNoSchool Name*Is Dependent 3 disabled?*Disabled is defined as they are on a disability program.YesNoOfficial Documentation for disabled dependents*You must provide official documentation PRIOR to electronically submitting a return. Examples of documentation may include, but not be limited to, the following: Disability Letter from Doctor (will be verified), Notice from Social Security Administration, Immobility Card with Photo ID, etc. Drop files here or Did the dependent reside with you for at least 6 months this past year?*YesNoDependent 3’s relationship to you*sondaughterbrothersisterstep childniecenephewgrandchildcourt-ordered foster childadopted childPlease upload Proof / Court Documents* Drop files here or Who are the Biological Parents?Biological Mother's Name* First Middle Last Biological Father's Name* First Middle Last Dependent 4Name* First Last SS#*Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Does Dependent 4 attend daycare or before/after school care?*YesNoName of care provider / institution:*Is Dependent 4 a student? (elementary, middle, high school, college)?*YesNoSchool Name*Is Dependent 4 disabled?*Disabled is defined as they are on a disability program.YesNoOfficial Documentation for disabled dependents*You must provide official documentation PRIOR to electronically submitting a return. Examples of documentation may include, but not be limited to, the following: Disability Letter from Doctor (will be verified), Notice from Social Security Administration, Immobility Card with Photo ID, etc. Drop files here or Did the dependent reside with you for at least 6 months this past year?*YesNoDependent 4’s relationship to you*sondaughterbrothersisterstep childniecenephewgrandchildcourt-ordered foster childadopted childPlease upload Proof / Court Documents* Drop files here or Who are the Biological Parents?Biological Mother's Name* First Middle Last Biological Father's Name* First Middle Last Dependent 5Name* First Last SS#*Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Does Dependent 5 attend daycare or before/after school care?*YesNoName of care provider / institution:*Is Dependent 5 a student? (elementary, middle, high school, college)?*YesNoSchool Name*Is Dependent 5 disabled?*Disabled is defined as they are on a disability program.YesNoOfficial Documentation for disabled dependents*You must provide official documentation PRIOR to electronically submitting a return. Examples of documentation may include, but not be limited to, the following: Disability Letter from Doctor (will be verified), Notice from Social Security Administration, Immobility Card with Photo ID, etc. Drop files here or Did the dependent reside with you for at least 6 months this past year?*YesNoDependent 5’s relationship to you*sondaughterbrothersisterstep childniecenephewgrandchildcourt-ordered foster childadopted childPlease upload Proof / Court Documents* Drop files here or Who are the Biological Parents?Biological Mother's Name* First Middle Last Biological Father's Name* First Middle Last Dependent 6Name* First Last SS#*Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Does Dependent 6 attend daycare or before/after school care?*YesNoName of care provider / institution:*Is Dependent 6 a student? (elementary, middle, high school, college)?*YesNoSchool Name*Is Dependent 6 disabled?*Disabled is defined as they are on a disability program.YesNoOfficial Documentation for disabled dependents*You must provide official documentation PRIOR to electronically submitting a return. Examples of documentation may include, but not be limited to, the following: Disability Letter from Doctor (will be verified), Notice from Social Security Administration, Immobility Card with Photo ID, etc. Drop files here or Did the dependent reside with you for at least 6 months this past year?*YesNoDependent 6’s relationship to you*sondaughterbrothersisterstep childniecenephewgrandchildcourt-ordered foster childadopted childPlease upload Proof / Court Documents* Drop files here or Who are the Biological Parents?Biological Mother's Name* First Middle Last Biological Father's Name* First Middle Last Dependent 7Name* First Last SS#*Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Does Dependent 7 attend daycare or before/after school care?*YesNoName of care provider / institution:*Is Dependent 7 a student? (elementary, middle, high school, college)?*YesNoSchool Name*Is Dependent 7 disabled?*Disabled is defined as they are on a disability program.YesNoOfficial Documentation for disabled dependents*You must provide official documentation PRIOR to electronically submitting a return. Examples of documentation may include, but not be limited to, the following: Disability Letter from Doctor (will be verified), Notice from Social Security Administration, Immobility Card with Photo ID, etc. Drop files here or Did the dependent reside with you for at least 6 months this past year?*YesNoDependent 7’s relationship to you*sondaughterbrothersisterstep childniecenephewgrandchildcourt-ordered foster childadopted childPlease upload Proof / Court Documents* Drop files here or Who are the Biological Parents?Biological Mother's Name* First Middle Last Biological Father's Name* First Middle Last Dependent 8Name* First Last SS#*Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Does Dependent 8 attend daycare or before/after school care?*YesNoName of care provider / institution:*Is Dependent 8 a student? (elementary, middle, high school, college)?*YesNoSchool Name*Is Dependent 8 disabled?*Disabled is defined as they are on a disability program.YesNoOfficial Documentation for disabled dependents*You must provide official documentation PRIOR to electronically submitting a return. Examples of documentation may include, but not be limited to, the following: Disability Letter from Doctor (will be verified), Notice from Social Security Administration, Immobility Card with Photo ID, etc. Drop files here or Did the dependent reside with you for at least 6 months this past year?*YesNoDependent 8’s relationship to you*sondaughterbrothersisterstep childniecenephewgrandchildcourt-ordered foster childadopted childPlease upload Proof / Court Documents* Drop files here or Who are the Biological Parents?Biological Mother's Name* First Middle Last Biological Father's Name* First Middle Last Dependent 9Name* First Last SS#*Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Does Dependent 9 attend daycare or before/after school care?*YesNoName of care provider / institution:*Is Dependent 9 a student? (elementary, middle, high school, college)?*YesNoSchool Name*Is Dependent 9 disabled?*Disabled is defined as they are on a disability program.YesNoOfficial Documentation for disabled dependents*You must provide official documentation PRIOR to electronically submitting a return. Examples of documentation may include, but not be limited to, the following: Disability Letter from Doctor (will be verified), Notice from Social Security Administration, Immobility Card with Photo ID, etc. Drop files here or Did the dependent reside with you for at least 6 months this past year?*YesNoDependent 9’s relationship to you*sondaughterbrothersisterstep childniecenephewgrandchildcourt-ordered foster childadopted childPlease upload Proof / Court Documents* Drop files here or Who are the Biological Parents?Biological Mother's Name* First Middle Last Biological Father's Name* First Middle Last Document UploadsPlease enter your tax payer information above before uploading documents.You have not submitted a completed form. Please complete the entire intake form once before uploading additional documents.Please upload all files here*Please upload your driver’s license, any birth certificates, W-2s, 1099s, mortgage statements, proof of residency, etc. Drop files here or Accuracy AcknowledgmentConsent*I attest that the above information is accurate and true to the best of my knowledge. I understand that if any of the above information provided is not true, I can be held personally liable for all fees associated with filling my federal and state income tax return fees electronically. I have also attested to the accuracy of the information denoted by my consent above. I agree to the Following:Disclosures - “All” SituationsConsent is sought for use of tax return information under any circumstance. Federal law requires this consent form be provided to you. Unless authorized by law, we cannot use, without your consent, your tax return information for purposes other than the preparation and filing of your tax return. You are not required to complete this form. If we obtain your signature on this form by conditioning our services on your consent, your consent will not be valid. Your consent is valid for the amount of time that you specify. If you do not specify the duration of your consent, your consent is valid for one year.Consent*Please note the above consent is for preparation of your income tax returns. Internal Revenue Service requires additional consent to disclose tax return information beyond preparation. If you will need this information provided from Chronicles of Numbers, LLC to another party, you are required to complete additional disclosures. Examples where additional disclosures will be needed are for mortgages, vehicle loans, etc. I authorize Chronicles of Numbers, LLC to use all income tax documents, schedules, etc., for any purpose requested by the tax preparer or the client.PRIVACY STATEMENTIf you believe your tax return information has been disclosed or used improperly in a manner unauthorized by law or without your permission, you may contact the Treasury Inspector General for Tax Administration (TIGTA) by telephone at 1-800-366-4484, or by email at complaints@tigta.treas.gov. PRIVACY STATEMENT Your privacy is very important to us at Chronicles of Numbers, LLC. We are providing this statement to inform you about the types of information we collect from you, and how we may disclose or use that information in connection with the services we provide. This Privacy Statement describes the privacy practices of our company as required by law. During the course of providing our services to you, we may offer you various other services that may be of interest to you based on our determination of your needs through analysis of your data. Your use of the services we offer constitutes consent to our disclosure of tax information to the service providers. If at any time you wish to limit your receipt of promotional offers based upon information you provide, you may call us at (318) 424-6532.Your Signature*More InformationOur goal is to provide you with financial education and assistance beyond your annual tax return.Please check below if you would like more information on any of the following services (select all that apply): Select All Business Startup Business Checkup (existing businesses) Paying off debt/Financial Independence Life insurance (personal or key man coverage for business) Legal protection (will, living will, power of attorney, traffic tickets, other personal legal matters) for you, your business, or employees Identity theft protection
