* TAX PAYER NAME: ---------------------------------- DATE OF BIRTH: ----------/--------/----------
SOCIAL SECURITY NUMBER:[ ][ ][ ] - [ ][ ] - [ ][ ][ ][ ]
OCCUPATION: ----------------------------------------------------------------------------------------------
HOME NUMBER: ( ) [ ][ ][ ] - [ ][ ][ ][ ]
WORK NUMBER: ( ) [ ][ ][ ] - [ ][ ][ ][ ]
==================================================================================
* SPOUSE NAME: -------------------------------------- DATE OF BIRTH: ----------/--------/----------
SOCIAL SECURITY NUMBER:[ ][ ][ ] - [ ][ ] - [ ][ ][ ][ ]
OCCUPATION: ----------------------------------------------------------------------------------------------
HOME NUMBER: ( ) [ ][ ][ ] - [ ][ ][ ][ ]
WORK NUMBER: ( ) [ ][ ][ ] - [ ][ ][ ][ ]
* STREET ADDRESS: -------------------------------------------------------------------------------------
CITY: ---------------------------------------------- STATE: --------------- ZIP CODE: -------------------
TAX PAYER SPOUSE MARITAL STATUS
BLIND: YES NO BLIND: YES NO MARRIED Will You File Joint: YES NO
DISABLED: YES NO DISABLED: YES NO SINGLE Date of Divorce: -------------------------
WIDOW(ER) Date of Spouse's Death: ----------
HEAD OF HOUSEHOLD
DEPENDENTS: List Names of all dependents, regardless of age, who received more than half of their support from you.
*NOTE: DO NOT LIST SPOUSE'S NAME
FIRST/LAST RELATIONSHIP DOB SOC SEC# MONTH DISABLED FT DEPENDENT'S
NAME LIVED (Y/N) STUDENT GROSS
WITH YOU INCOME
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
CHILD & DEPENDENT CARE EXPENSE
NAME ADDRESS SOC SEC# / EIN NAME OF AMOUNT PAID
CITY,STATE,ZIP CODE QUALIFYING PERSON
$ , .00
$ , .00
$ , .00
FOR DC TAXPAYERS ONLY
Did you rent or own your hime for the whole year? YES NO
Did you live in Public Housing? YES NO
Amount of Rent Paid? $ ______________ MONTHLY ANNUAL
LandLord's Name: ______________________ Phone#: ________________ Address _________________________
Lot#: _______________________ Real Estate Tax $ ______________________________
_______________________________________________________________________________________________
You are required by law to keep records that will enable you to prepare a complete and accurate income tax return. You must retain all receipt, canceled checks and other evidence to prove amounts claimed as deductions. Enclose all W-2's, 1099s, 1098 and all other necessary documents. |
