Bennett Financial - Financial Review Intake Form

This form is to be completed by the taxpayer to give us an idea of your monthly expenses. Submitting this information will help us build your case properly. This will allow us to better negotiate with the IRS and/or State Taxing Authority on your behalf. Thanks in advance for taking the time to complete this form. Please be advised that we may need the actual statements for all expenses listed in the future.

Client Name: Client Name: First Last
Client Date of Birth Client Date of Birth / MM / DD YYYY
Spouse's Name: (If Applicable) Spouse's Name: (If Applicable) First Last
Spouse Date of Birth: (If Applicable) Spouse Date of Birth: (If Applicable) / MM / DD YYYY
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
How Many Dependents Do You Have?
Dependent Information
Dependent Name Dependent Name First Last
Dependent SSN
Dependent Birthdate Dependent Birthdate / MM / DD YYYY
Dependent Name Dependent Name First Last
Dependent SSN
Dependent Birthdate Dependent Birthdate / MM / DD YYYY
Dependent Name Dependent Name First Last
Dependent SSN
Dependent Birthdate Dependent Birthdate / MM / DD YYYY
If You Have More Than 3 Dependents, Please Enter The Others Name, SSN and Date Of Birth Here
HOUSEHOLD EXPENSE INFORMATION SECTION
Do You Own Or Rent Your Home?
How Much Is Your Rent/Mortgage Payment Monthly?
If Applicable, How Much Is Still Owed On Your Mortgage (estimated)?
How Much Is Your Electric Bill Each Month?
How Much Is Your Water and Sewer Bill Monthly?
How Much Is Your Cable / Internet / Telephone Bill Monthly?
INSURANCE INFORMATION SECTION
Do You Have Health / Dental Insurance?
If YES, How Much Is Your Monthly Premium?
Do You Have Life Insurance?
If YES, How Much Is Your Monthly Premium?
Do You Have Vehicle Insurance?
If YES, How Much Is Your Monthly Premium?
CHILDCARE / CHILD SUPPORT / ALIMONY INFORMATION SECTION
Do You Pay Child Support?
If YES, How Much Do You Pay Each Month For Childcare?
When Does Your Child Support Requirement End?
Do You Pay For Childcare Each Month?
If YES, How Much Do You Pay Each Month For Childcare?
Do you Pay Child Support or Alimony Each Month?
If YES, How Much Do You Pay In Child Support or Alimony Monthly?
MISC. EXPENSES YOU MAY PAY THAT ARE NOT LISTED

Please use this section to enter in any expenses not listed on the form that you want us to know about.
Please List Any Other Expenses You Pay For Monthly Below:
BANK ACCOUNT INFORMATION SECTION

Please Advise Us Of All Bank Accounts With Your Name On Them
What Bank(s) Do You Have Accounts With Currently? Please Include Both Joint and Individual Accounts
Please Upload Your Bank Statements For The Last Three (3) Months (All pages are needed)

Attach Files
PAY STUB SECTION

Self-employed may skip this part
Please upload most recent pay stub that shows YTD figures (within the last 30 days is considered recent)
(Self-employed may skip this part)

Attach Files
ASSET INFORMATION SECTION

This section includes vehicles, boats, property, IRA's, 401K's
Do You Have ANY Vehicles In Your Name?
What Is The Year, Make and Model Of Your Vehicle?
How Many Miles Are On This Vehicle?
How Much Is Your Monthly Car Payment? (If Applicable)
What Is The Year, Make and Model Of Your 2nd Vehicle? (If Applicable)
How Many Miles Are On This Vehicle? - (if applicable)
How Much Is Your Monthly Car Payment For Your 2nd Vehicle? (If Applicable)
How Much Is Still Owed On This Vehicle (if applicable)
What Is The Year, Make and Model Of Your 3rd Vehicle? (If Applicable)
How Many Miles Are On This Vehicle? - (if applicable)
How Much Is Still Owed On This Vehicle (if applicable)
How Much Is Your Monthly Car Payment For Your 3rd Vehicle? (If Applicable)
How Much Is Still Owed On This Vehicle (if applicable)
Do You Have A 401K or An IRA?
If YES, what is the value of your 401k currently?
Do You Have Loans Against Your 401K?
Do You Own Any Boats, ATV's or Motorcycles?
If Yes, What Year, Make And Model Is Your Boat, ATV or Motorcycle?
Do You Own Any Real Property, Land Or Timeshares?
If Yes, What Is The Address Of Your Real Property, Land Or Timeshare?
Is There A Mortgage On The Real Property, Land or Timeshare?
If Yes, Please Upload A Mortgage Statement No Older Than 30 Days

Attach Files
MISC. INFORMATION SECTION
Please Use This Area To Tell Us Anything You Feel May Be Important Regarding Your CURRENT Financial Situation: (EX: Health Issues, Recently Unemployed, Recently Married, Etc...)
SIGNATURE AND CERTIFICATION SECTION
Draw your signature into the box below to submit this information to us. By doing so, you are certifying that the expense and asset information is accurate to the best of your knowledge.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Upload a File

Attach Files

Bennett Financial - Financial Review Intake Form

Bennett Financial - Financial Review Intake Form

Dependent Information

HOUSEHOLD EXPENSE INFORMATION SECTION

INSURANCE INFORMATION SECTION

CHILDCARE / CHILD SUPPORT / ALIMONY INFORMATION SECTION

MISC. EXPENSES YOU MAY PAY THAT ARE NOT LISTED

BANK ACCOUNT INFORMATION SECTION

PAY STUB SECTION

ASSET INFORMATION SECTION

MISC. INFORMATION SECTION

SIGNATURE AND CERTIFICATION SECTION