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Please provide every W-2, 1099, 1098 and any applicable papers needed to file your taxes, including any expenses receipts. If you are a new customer, please bring in last year’s returns.

Your Name:__________________________________________________________

Spouse’s Name:______________________________________________________

Residential Address:__________________________________________________


Mailing Address (if different):___________________________________________


Telephone Number:___________________________________________________

Your SSN:_______________________ Spouse’s SSN:___________________

Your DOB:_______________________ Spouse’s DOB:___________________

Legally Blind: You______________ Spouse:_____________

Your Occupation:_____________________ Spouse’s Occupation:______________

Can anyone else claim you as a dependent? You__________ Spouse:_________

Is this return for a deceased person, If Date of Death?______________________________________

Filing Status:

____ Single    ____ Married filing a joint return    ____ Married filing separate

____ Head of Household    ____ Qualifying Widow(er)   Year Spouse Died:_______

If filing as Head of Household, and qualifying person is a child but not your dependent

Enter Child’s Name_____________________ SSN_______________________

Do you have any dependents? ____Yes ____No

Name:_________________________________ SSN________________________

Date of Birth:_________________________ Relationship:_______________

How long lived with you: ___Months

If more than one dependent , please send an email with the rest. Or print this form and add it.

Do you pay rent?    Yes____ No____, How Much_________

Do you own a house? Yes____ No____ Have rental income? Yes____ No____

Last year’s Adjusted Gross Income? ____________

Please Circle One, If a refund how do you prefer to receive your money?

                          Direct Deposit         or         Check (by mail)

Bank Name_____________________________ CK or Sav Account (circle one)

Routing #_______________________ Account_______________________

Do you have health insurance? yes____ no ____ Insurance policy #_______________

Health Connector for even only 1 day on the year? bring Form 1095-A

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