Tax Year
Filing Status
SingleMarriedSeparatedWidow(er)
First Name
Middle Initial
Last Name
Social Security Number
Birthday
Main Phone
Address
City
State
Occupation
Dependent Name
Social Security #
Birth Date
Relationship
Months Lived In Home
Are either you or your spouse legally blind?
YesNo
Can someone else claim you as a dependent?
You or your spouse a resident of another state, or earned income in another state?
If Yes, State(s)
Did you purchase health insurance through a public exchange?
Did you have cancellation of debt including bankruptcy, foreclosure or repossession?
Do you have any educational or tuition expenses?
Please Provide Your 1098T
Account Type
CheckingSavings
Account Number
Routing Number
Bank Name
Taxpayer State
State ID #
Issue Date
Expiration Date
Spouse State
Spouse State ID #
County
Township (If Needed)
School District
PSD #
Tax Rate %
