Full Legal Name *

Date of birth *

Social Security Number *

Phone *

Email *

Address *

Residential Address

City

State

Country

Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic of the
Cook Islands
Costa Rica
Cote D"Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic Of
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea People's Democratic Republic
Republic of Korea
Kuwait
Kyrgyzstan
Land Islands
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
North Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Federated States of Micronesia
Moldova, Republic of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Helena
Saint Kitts and Nevis
Saint Lucia
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Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
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Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
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Spain
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Eswatini
Sweden
Switzerland
Syrian Arab Republic
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Tanzania, United Republic of
Thailand
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Turkey
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UK
Ukraine
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Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
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Postal Code

Mailing Address if Different

Citizenship Status *

US Citizen
Resident Alien
Non Resident
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Marital Status *

Single
Married Filing Joint
Married Filing Separate
Head of Household
Qualifying Widowed
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Spouse Full Legal Name *

Spouse Date of Birth *

Spouse Social Security Number *

Spouse Phone Number *

Spouse Email Address *

Taxpayer Government Issued ID *

Spouse Government Issued ID *

Social Security Cards for Everyone on Return *

Prior Year Tax Return (Optional)

How many dependents do you have? *

0 Dependents

1 Dependent

2 Dependents

3 Dependents

4 Dependents

5 Dependents

Dependent 1 Full Name *

Dependent 1 Date of Birth *

Dependent 1 Social Security Number *

Dependent 1’s Relationship to You *

Months Dependent 1 Lived With You This Year ✅ *

Is Dependent 1 a full-time student? *

Yes

No

Is Dependent 1 disabled? *

Yes

No

Dependent 1 Birth Certificate *

Dependent 1 Social Security Card *

Dependent 1 School or Medical Residency Documents *

Dependent 1 Court or Guardianship Documents (if applicable)

Dependent 2 Full Name *

Dependent 2 Date of Birth *

Dependent 2 Social Security Number *

Dependent 2’s Relationship to You *

Months Dependent 2 Lived With You This Year *

Is Dependent 2 a full-time student? *

Yes

No

Is Dependent 2 disabled? *

Yes

No

Dependent 2 Birth Certificate *

Dependent 2 Social Security Card *

Dependent 2 School or Medical Residency Documents *

Dependent 2 Court or Guardianship Documents (if applicable)

Dependent 3 Full Name *

Dependent 3 Date of Birth *

Dependent 3 Social Security Number *

Dependent 3’s Relationship to You *

Months Dependent 3 Lived With You This Year *

Is Dependent 3 a full-time student? *

Yes

No

Is Dependent 3 disabled? *

Yes

No

Dependent 3 Birth Certificate *

Dependent 3 Social Security Card *

Dependent 3 School or Medical Residency Documents *

Dependent 3 Court or Guardianship Documents (if applicable)

Dependent 4 Full Name *

Dependent 4 Date of Birth *

Dependent 4 Social Security Number *

Dependent 4’s Relationship to You *

Months Dependent 4 Lived With You This Year *

Is Dependent 4 a full-time student? *

Yes

No

Is Dependent 4 disabled? *

Yes

No

Dependent 4 Birth Certificate *

Dependent 4 Social Security Card *

Dependent 4 School or Medical Residency Documents *

Dependent 4 Court or Guardianship Documents (if applicable)

Dependent 5 Full Name *

Dependent 5 Date of Birth *

Dependent 5 Social Security Number *

Dependent 5’s Relationship to You *

Months Dependent 5 Lived With You This Year *

Is Dependent 5 a full-time student? *

Yes

No

Is Dependent 5 disabled? *

Yes

No

Dependent 5 Birth Certificate *

Dependent 5 Social Security Card *

Dependent 5 School or Medical Residency Documents *

Dependent 5 Court or Guardianship Documents (if applicable)

Number of W2 Forms Received *

Upload All W2 Forms *

Describe Your Self Employment or Side Business *

Business Name *

Employer Identification Number (EIN) *

Business Address *

Type of Business *

Total Gross Income *

Total Expenses *

Bookkeeping Method or Notes *

Upload All 1099 NEC and 1099 MISC Forms *

Upload Income Log or Bookkeeping Records *

Upload Profit and Loss Statement *

Gig Work Income *

Uber

Lyft

DoorDash

Instacart

Amazon Flex

Airbnb

Turo

Upwork

Fiverr

Other

Upload Gig Work 1099 or Year-End Statements *

Other Income Types *

Unemployment (1099 G)

Social Security (SSA 1099)

Disability

Pension or Retirement (1099 R)

Interest or Dividends (1099 INT / DIV)

Stock Sales (1099 B)

Cryptocurrency

Rental Income

Child Support Received

Alimony Received

Gambling Winnings (W2 G)

Foreign Income

Upload Other Income Supporting Documents *

Upload 1098 T Form *

Upload Tuition Receipts *

Upload Student Loan Interest (1098 E) *

What is the child care provider’s name? *

What is the child care provider’s phone number? *

What is the child care provider’s address? *

What is the child care provider’s Tax ID? *

What is the total amount paid for child care? *

Summary of Medical Dental and Prescription Expenses *

Upload 1098 Mortgage Interest *

Upload Property Tax Statement *

Upload Closing Documents *

List Cash and Non Cash Donations *

1
2
3
4
5
6

Upload Donation Receipts

IRA and Additional Retirement Contributions *

Upload Solar or Energy Credit Documentation *

Are you self-employed or a business owner? *

Yes

No

Entity Type *

LLC

S Corp

Partnership

Sole Proprietor

Date Business Was Formed *

Upload Articles of Organization *

Upload Prior Year Business Tax Return *

Upload Operating Agreement *

Profit and Loss Statement *

Balance Sheet *

Business Bank Statements *

Payroll Reports *

1099s You Issued *

Inventory or Asset Purchase Receipts *

Total Home Square Footage *

Square Footage Used for Business *

List Home Expenses (rent mortgage utilities internet repairs etc.) *

Did You Have Marketplace Health Insurance *

Yes

No

Upload 1095 A *

Upload 1095 B (Optional)

Upload 1095 C (Optional)

Refund Method *

Direct Deposit

Paper Check

Bank Name *

Routing Number *

Account Number *

Account Type (Checking/Savings) *

Upload Voided Check or Bank Letter *

Did your address change this year? *

Yes

No

Did you receive any IRS or state letters? *

Yes

No

Have you been a victim of identity theft?

Yes

No

Did you make estimated tax payments? *

Yes

No

Do you owe back taxes child support or student loans? *

Yes

No

Does someone else claim you? *

Yes

No

Did you buy sell or trade cryptocurrency? *

Yes

No

Did you win or lose gambling? *

Yes

No

Did you buy or sell a home? *

Yes

No

Upload IRS or State Notices

Additional Notes or Information *

Client Acknowledgements *

I confirm all information I provided is accurate

I understand Financial Dominance does not audit or verify information

I am responsible for reviewing my tax return before filing

I understand fees must be paid before filing

I understand incomplete information may cause delays penalties or interest

I agree to upload all required documents to the secure portal

I consent to communication by phone email text message and portal

Required Checkbox *

I certify that all information and documents I have provided are true correct and complete to the best of my knowledge and belief

Taxpayer Digital Signature *

Clear

Spouse Digital Signature (If Applicable)

Clear

Date Signed *