D5 Legacy Tax Intake Form

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If someone referred you, please type his or her name here.

Yes, up to $7500 with interest and feesNo, but thank you!

YesNo

Do you have an (IPIN) IRS Identity Protection Pin?

Yes or No. If Yes, please enter the numerical IPIN received.

If you have an (IPIN) Identity Protection Pin for yourself or dependents, upload a copy of your IPIN letter that shows your name and IPIN in this section.

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Tax Payers Name

First NameLast Name

Taxpayer's SSN

Example: xxx-xx-xxxx

Taxpayer's Date of Birth*

Example: 01/01/2001

Taxpayer's Job Title/ Occupation*

Taxpayer's Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Taxpayer's Phone Number*

Example: xxx-xxx-xxxx

Taxpayer's Email Address*

Are you legally blind or totally & permanently disabled?

YesNoNot Applicable

Spouse's Name

First NameLast Name

Spouse's Date of Birth

Example: 01/01/2001

Spouse's Job Title

Spouse's SSN

Example: xxx-xx-xxxx

Spouse's Phone Number

Example: xxx-xxx-xxxx

Spouse's Email Address

Example: example@example.com

YesNo

If you are self employed, do you have an EIN number? If you have an EIN number, please enter it below.

Example: 00-0000000

If you are self-employed, what type of work do you do?

If you were self employed, how were you paid? (Cash, Direct Deposit, Cash App/ Apple Pay, Invoicing System)

YesNo

Upload Taxpayer Unemployment Income Documents (1099-G, 1099-INT)

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Single (Not Married)Married living with SpouseMarried not living with spouse

YesNo

YesNoNot Applicable

How many dependents are you claiming?*

If you are claiming a child that is not your child, please provide a short explanation why their parent is not claiming the child on their tax return. (Short & simple there's no need for an essay here)

Dependent #1

First NameLast Name

Dependent #1 Date of Birth

01/01/2001

Dependent #1 SSN

What is Dependent #1's Relationship to you (son, daughter, etc.)?

How many months did Dependent #1 live with you in 2025? (If all year, enter 12)

Dependent #2

First NameLast Name

Dependent #2 Date of Birth

Example: 01/01/2001

Dependent #2 SSN

How many months did Dependent #2 live with you in 2025? (If all year, enter 12)

What is Dependent #2's Relationship to you (son, daughter, etc.)?

Dependent #3

First NameLast Name

Dependent #3's Date of Birth

01/01/2001

How many months did Dependent #3 live with you in 2025? (If all year, enter 12)

Dependent #3s SSN

Example: xxx-xx-xxxx

Dependent's #3 SSN

What is Dependent #3's Relationship to you (son, daughter, etc.)?

Dependent #4's First Name

First Name

Dependent #4's Last Name

Last Name

Dependent #4's Date of Birth

01/01/2001

Dependent #4's SSN

Example: xxx-xx-xxxx

What is Dependent #4's Relationship to you (son, daughter, etc.)?

How many months did Dependent #4 live with you in 2025? (If all year, enter 12)

Dependent #5's First Name

First Name

Dependent #5's Last Name

Last Name

Dependent #5's Date of Birth

01/01/2001

Dependent #5's SSN

Example: xxx-xx-xxxx

What is Dependent #5's Relationship to you (son, daughter, etc.)?

How many months did Dependent #5 live with you in 2025? (If all year, enter 12)

YesNo

Upload a copy of your daycare form here.

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Direct DepositPrepaid Card (Available for in office visits or Overnight shipping)

Name of Bank (For Refund Direct Deposit)

Checking AccountSavings AccountOther

Routing Number

Bank Account Number

YesNo

Who was your insurance coverage through in 2025?

YesNo

Upload Taxpayer & Dependent(s) Insurance Documents (1095-A, 1095-B)

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YesNo

If you have a 1098-T form, upload it here.

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CLIENT NON PAYMENT/OFFSET CLAUSE

At D5 Legacy LLC, we strive to assist all of our clients in their tax needs, however we understand that situations arise. If your refund is offset by the IRS, student loans, child support or your check is mailed, you are still obligated to pay our company the fees associated with filing your tax return.

By signing this agreement you acknowledge that if payment is not made in full with in 30 days legal actions will be sought to resolve payment.

Primary Taxpayer's Signature

ADDITIONAL SERVICES

At D5 Legacy LLC, we do more than just taxes. Please send an email to contact@d5legacyllc.com if you would be interested in any of the additional services we provide. We will schedule a time to speak with you at a later time.

Business Credit Establishment $500 (For REGISTERED LLCS)

I am giving D5 Legacy LLC permission to prepare all forms related to my tax return; to apply for and secure RAC's and RAL's on my behalf; and sign all necessary forms and file my taxes electronically. I take full responsibility for the accuracy of this form and understand that D5 Legacy LLC and/or associated affiliates hold no responsibility for any misrepresentation or false claims.

Date

Taxpayer's Signature (If no spouse, leave blank)

Spouse's Signature (If no spouse, leave blank)

Date

Taxpayer's Driver's License or State ID*

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SELFIE holding your Driver’s License/State ID*

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Required for security and identity verification

Taxpayer's and Dependent(s ) Social Security Card(s)

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Taxpayer's Proof of Income: W-2s/ 1099s, Unemployment 1099-G, Proof of Self Employment/ Business Income & Expenses

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Dependent(s) Birth Certificate(s)

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Dependent(s) Proof of Residency (Lease/Utility Bill)

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Prior Year Tax Return (If you are not a previous client)

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CLIENT FORM