Please read carefully and fill out any items that apply to you. If there is anything else I should know about, please include it in the comments section below. Personal Information First Name: * Last Name: * Date of Birth * Social Security #: Street Address 1: * Street Address 2: City: * State: * Postal Code: * Email: * Phone: * Alternate Phone: Occupation: * Driver’s License State of Issue: * Driver’s License Number: * Driver’s License Issue Date: * Driver’s License Expiration Date: * Spouse’s Information Spouse Name: Social Security # (Spouse): Email (Spouse): Cell Phone (Spouse): Alternate Phone (Spouse): Date of Birth (Spouse): Occupation (Spouse): Driver’s License State of Issue (Spouse): Driver’s License Number (Spouse): Driver’s License Issue Date (Spouse): Driver’s License Expiration Date (Spouse): Filing Status Single Married Married but filing Separate (Give spouse’s name/SSN/birthdate) Lived separate from spouse for last 6 months of year Divorced Divorced Date: Head of Household (unmarried with dependent(s)) Widowed Widowed Date: Dependents (1) Dependent Name: (1) Dependent Social Security #: (1) Dependent Date of Birth: (1) Dependent Relationship: (1) Dependent lived with you all year? (2) Dependent Name: (2) Dependent Social Security # (2) Dependent Date of Birth: (2) Dependent Relationship: (2) Dependent lived with you all year? (3) Dependent Name: (3) Dependent Social Security #: (3) Dependent Date of Birth: (3) Dependent Relationship: (3) Dependent lived with you all year? Health Had health insurance the whole year. Did not have health insurance for a period of time. If yes, list the months you did not have health insurance: Bought health insurance on the ACA marketplace/exchange – If so, we need Form 1095-A. Spent more than 7.5% of my income on medical expenses. If more than 7.5% of income, what amount was spent on medical expenses? If more than 7.5% of income, what were the medical expenses? Childcare Incurred childcare expenses while working/school full-time. Amount spent on childcare: Childcare Provider: Provider SSN/EIN: Provider Address: Provider Phone: Education Incurred educational expenses for: College Graduate School K-12 For: Self Spouse Dependent(s) Which dependent(s)? Amount spent on education: Foreign Accounts I have over $10,000 in a foreign bank account. IRA Contributions Made Traditional IRA (Not Roth) contributions (outside of work). Amount of IRA contribution for myself: Amount of IRA contribution for spouse: Moving Expenses Moved this year and and was in the U.S. military Date of Move: Moved from (city, state): Moved to (city, state): Spent $______ on moving/storage: Spent $_____ on travel/lodging: Moved 50 miles closer to work If you moved more than 50 miles closer to work, did your workplace change? If you moved more than 50 miles closer to work, was it a temporary assignment? Quarterly Estimated Taxes Sent in quarterly Estimated Taxes Dates & amounts sent of quarterly Estimated Taxes: Charitable Contributions Donated money to charity Total amount donated: Donated items to charity Estimated value of donated items: If over $500 worth of items donated we’ll need to know: Which charity? What kind of items? Clothing Furniture Household items Other If other, list type of items donated: Drove __________ miles doing volunteer work for a 501c3 charity. Last Year’s Taxes Spent $_________ to get my tax return prepared last year. (That amount is deductible this year if itemizing). I received a refund from the IRS Approximate amount of IRS refund: I received a refund from the state Approximate amount of state refund: I owed money to the IRS Approximate amount owed to IRS: I owed money to the state Which state? Approximate amount owed to state: Refund Information Deposit my refund (if I receive one) directly into my bank account. Bank Name: Routing # (9 digits): Account #: Additional Information How did you find us? Referred by: Did anything else happen this year that might influence your taxes? Submit
