Client Intake Form

Please set aside at least 20 minutes to complete the intake form. Completing this form is REQUIRED to ensure your personal and/or business income and expenses are filed accurately and to ensure full compliance with IRS regulations. If you need assistance, please call 337-849-4993 or email [email protected] thank you!

BASIC INFORMATION

How did you hear about us?

Are you interested in the refund cash advance?

YES

NO

Are you interested in credit repair?

YES

NO

Are you a new or returning tax client? *

New Tax Client

Returning Tax Client

Did you receive a refund last year? *

Yes

No

I had tax issues last year

Do you have any unfilled tax returns from previous years? *

Yes

No

Street Address *

City

State

Country

Postal Code

Taxpayer Full Name *

Taxpayer Date of Birth *

Taxpayer Social Security Number *

** PHOTO ID CANNOT BE EXPIRED **

UPLOAD your License and Social Card *

Was your main home in the US for more than 6 months ? *

Yes

No

2025 Identity Protection Pin & who it was issued to:

Upload IP PIN LETTER

Email *

Best Phone Number *

Were you audited by the IRS last year? *

Yes, which is why I need professional help.

No

Can anyone claim you or your spouse as dependent? *

Yes

No

Spouse Full Name

Spouse Date Of Birth

Spouse Social Security Number

UPLOAD your Spouse License and Social Card

Health Insurance

Did you, your spouse or dependents receive health insurance through the Marketplace in 2024 and receive Form 1095-A?

Yes

No

Upload Form 1095-A

Income

Did you or your spouse work?

Yes

No

Upload corresponding documents (W-2, 1099, etc.)

Did you receive unemployment compensation this year? (1099-G)

Yes

No

Please upload form 1099-G

Did you make an early withdrawal from your 401K/IRA?

Yes

No

Upload corresponding documents (401K/IRA)

Did you receive any gambling winnings, lottery winnings, prizes, or other awards?

Yes

No

Upload corresponding documents (gambling winnings, lottery winnings, prizes, or other awards)

Self Employment

Do you own a business OR are self employed?

Yes

No

Do you have an Employer Identification Number (EIN) for your business?

Yes

No

If so, what is your business EIN number?

What kind of business do you own?

Dependent(s)

Are you claiming any dependents this year? If claiming dependent(s) please input info below. *

Yes

No

Dependent (1) Full Name

Dependent (1) Social Security #

Dependent (1) Date of Birth

Dependent (1) Relationship

Dependent (2) Full Name

Dependent (2) Social Security #

Dependent (2) Date of Birth

Dependent (2) Relationship

Dependent (3) Full Name

Dependent (3) Social Security #

Dependent (3) Date of Birth

Dependent (3) Relationships

UPLOAD all dependent(s) Social Cards

Do you or your spouse owe debt to any Government Agency; such as IRS, Student Loans, Child Support etc?

Which government agency do you owe?

Did you or anyone in your household attend a college or university this year?

Yes

No

Upload form 1098-T (tuition statement)

Almost done!

If due a refund, would you prefer direct deposit?

Yes

No, I prefer a paper check.

I would like a Visa Prepaid Card

Bank Name

Account Number

Routing Number

To your knowledge, do you currently owe the IRS *

Please upload any additional tax documents you received that the questionnaire did not request.

Client Authorization Statement
I fully agree, everything is accurate information with no false documents

Do you understand that once your tax return is submitted, you are no longer waiting on Unique Secured Tax Service but are instead waiting on the IRS?

Yes, I understand.

Letter of Engagement

Thank you for choosing Unique Secured Tax Service, LLC to assist you with your requested year taxes. This letter confirms the terms of our engagement with you and outlines the nature and extent of the services we will provide.

Scope of Services

We will prepare your requested federal and state income tax returns. We will depend on you to provide the information we need to prepare complete and accurate returns. The law imposes penalties when taxpayers underestimate their tax liability. We may ask you to clarify some items but will not audit or otherwise verify the data you submit.

We will perform accounting services only as needed to prepare your tax returns. Accordingly, our engagement should not be relied upon to disclose errors, fraud, or other illegal acts, though it may be necessary for you to clarify some of the information you submit. We will, of course, inform you of any material errors, fraud, or other illegal acts we discover.

Client Acknowledgment

I acknowledge that all information provided to Unique Secured Tax Service LLC is true and accurate to the best of my knowledge. I understand that I am required to have supporting documentation to validate the information provided.

Furthermore, I understand that knowingly providing false information on my tax return and reporting it to the IRS means I may be subject to criminal penalties, including but not limited to: court proceedings, restitution, and possible imprisonment.

I waive Unique Secured Tax Service, LLC and the preparer of any error due to incorrect information provided by me. By signing below, I authorize Unique Secured Tax Service, LLC to file my tax return.

Fees and Payment

I acknowledge that if I and/or my spouse owe a federal or government debt (IRS, child support, student loans, etc.), I/we are still responsible for tax preparation fees due to Unique Secured Tax Service, LLC at the time of service.
If the federal refund amount is mailed, I/we are still responsible for the tax preparation fees stated on the invoice.
If I choose not to proceed with tax preparation after the return is complete, I agree to pay a $99 non-filing fee, due immediately. If unpaid, I will be required to pay the full preparation fee stated on my invoice.
If tax preparation fees are not paid, I understand Unique Secured Tax Service LLC may take legal action to collect, including reporting to credit bureaus.
I agree not to dispute fees for services rendered due to IRS delays or refund garnishments.

Invoices are due and payable upon presentation. We will return your original records at the end of this engagement. You should securely store these records, along with all supporting documents, canceled checks, etc., as they may be needed to prove accuracy and completeness of your return. We will retain copies of your records and work papers for three (3) years, after which these documents will be destroyed. Paper copies of the tax return and other documents will be available for a fee.

Fees and Payment

Our engagement to prepare your tax returns will conclude with:

Delivery of the completed returns to you (if paper-filing), OR
Your signature and our submittal of your return (if e-filing).

If you do not choose e-filing, you will be solely responsible to file your returns with the appropriate taxing authorities. Review all tax-return documents carefully before signing.

You agree to allow Unique Secured Tax Service, LLC to file your tax return and understand that we do not provide price quotes comparable to DIY tax software.

You also agree to receive text messages and emails from Unique Secured Tax Service, LLC about your tax return and future opportunities.

Fees and Payment

To affirm that this letter correctly summarizes your understanding of the arrangements for this work, you agree to allow Unique Secured Tax Service to file your tax return.

Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge and belief, they are true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which the preparer has any knowledge.

Print Name of Taxpayer *

Date Signed *

CONSENT TO DISCLOSURE OF TAX RETURN INFORMATION

Consent to Use of Tax Return Information

For the purposes of this consent form, “we,” “us,” and “our” mean Unique Secured Tax Service

Federal law requires this consent form be provided to you. Unless authorized by law, we cannot use your tax return information for purposes other than the preparation and filing of your tax return without your consent.

You are not required to complete this form to engage in our tax return preparation services.
If we obtain your signature on this form by conditioning our tax preparation 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 from the date of signature.
If you do not consent, you may still have your tax return prepared and electronically filed by us for a fee.

For your convenience, we have entered into an arrangement with third parties to provide qualifying taxpayers with the opportunity to apply for an Electronic Refund Disbursement Service and/or Loan product. To determine whether these products may be available to you, we will need to use your tax return information in order to calculate the amount of your anticipated refund.

If you would like us to use your tax return information to determine whether these products may be available to you while we are preparing your return, please sign and date this consent to the use of your tax return information.

By signing below, you authorize Unique Secured Tax Service to use the information you provide to us during the preparation of your 2025 tax return to determine whether to present you with the opportunity to apply for these products and services.

Taxpayer Signature *

Clear

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