Dynamics Tax Intake Form

CLIENT INTAKE FORM
How did you hear about us?

FacebookInstagramReferralPrevious Client
If someone referred you, please type his or her name here. *
write N/A if not applicable
Are you trying to buy a new home within the next 2 years?*

YesNo
Are you interested in Credit Restoration or Life Insurance Products*

YesNo
Email*
example@example.com
Tax Payers Name

First NameLast Name
Taxpayer's Phone Number*
Example: xxx-xxx-xxxx
Taxpayer's Occupation *
Taxpayer's Date of Birth*
Example: 01/01/2001
Taxpayer's SSN*
Example: xxx-xx-xxxx
Taxpayer's Email Address*
Spouse's Full Name
First Name
Spouse's SSN
Example: xxx-xx-xxxx
Name

First NameLast Name
Spouse's Date of Birth
Example: 01/01/2001
Spouse's Phone Number
Example: xxx-xxx-xxxx
Spouse's Email Address
Example: example@example.com
Taxpayer's SSN
Example: xxx-xx-xxxx
Spouse's Job Title
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you self employed?*

YesNo
Did you and your spouse live apart during the year?*

YesNoNot Applicable
What is your marital status as of December*

Single (Not Married)Married living with SpouseMarried not living with spouse
Did you pay over half the expenses of maintaining your residence for the entire year?*

YesNo
Did you support a child or adult family member for more than 6 months out of the year?*

YesNo
Are you on any Government Assistance*

YesNoNot Applicable
How many dependents are you claiming?*
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 2024? (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 2024? (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 2019? (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 2019? (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 2019? (If all year, enter 12)
Are there any dependents in daycare? If yes, please upload the form you received from your daycare provider.

YesNo
Upload a copy of your daycare form here.

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How would you like to receive your tax refund?*

Check (sent via Fedex or Certified mail $25)Direct Deposit
Name of Bank*
Which type of account would you like your refund deposited into?*

Checking AccountSavings AccountOther
Routing Number *
Bank Account Number *
Can someone else claim you as a dependent?*

YesNo
Did you have health insurance in 2025?*

YesNo
Did you have health insurance for the entire year?*

YesNo
Was your insurance through your employer?*

YesNo
Was your insurance through Medicaid?*

YesNo
Was your insurance through the Affordable Care Act (The Marketplace)?*

YesNo
Did your dependents have health insurance for the entire year?*

YesNoNot Appliable
Was YOUR DEPENDENTS' insurance through your employer?*

YesNoNot Applicable
Who was your Dependents insured with in 2024?
Upload Taxpayer & Dependent(s)Insurance Documents 1095A

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Have you ever been denied the Earned Tax Credit (EITC)?*

YesNo
Were you or any of your dependents in college in 2025?

YesNoNot applicable
Do you have a 1098-T Form for either you or your dependents?*

YesNo
If yes, Do you have a 1098-T form? upload here.

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Did you trade any Virtual Currency (stocks or cryptocurrency)*

YesNo
If yes, Do you have form 8949?

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Do you own real estate?*

YesNo
If yes what year did you purchase your home in?
enter year
If yes, Do you have a form 1098? (found on mortgage co. online portal)

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CLIENT NON PAYMENT/OFFSET CLAUSE

At Dynamics Business & Tax Solutions we strive to assist all of our clients in their tax needs, howwever 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 90 days automatic bank collections and possible legal actions will be sought to resolve payment.
Primary Taxpayer's Signature

Clear
I am giving Dynamics Business & Tax Solutions 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 Dynamics Business & Tax Solutions and/or associated affiliates hold no responsibility for any misrepresentation or false claims.
Date*

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

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

Clear
Date

MonthDayYear
Date
Type a question
Date

MonthDayYear
Date
Taxpayer's Driver's License*

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

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Taxpayer's W-2/ 1099's/ 12 months bank statements

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Dependent(s) Birth Certificate(s)

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Taxpayers(s) Proof of Residency (Lease/Utility Bill)*

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Should be Empty:

CLIENT INTAKE FORM