Basic Taxpayer Information
Name:
EMail Address:
First Name and Initial
Last Name
Social Security
Taxpayer
Spouse
check if
Occupation
Birth Day
Over 65
Blind
Dependent of another Taxpayer
Presidential Election Contribution
Taxpayer
Spouse
Street Address:
City:
, State:
, Zip:
Home Phone
Area Code:
Number:
Work Phone
Area Code:
Number:
Filing Status - Check One
1. Single;
2. Married Filing Joint;
3. Married Filing Separate;
4. Head of Household;
5. Qualifying Widower
Dependent Information
Name: First Middle Last
Date of Birth
Social Security
# Months in Home
1.
2.
3.
4.
5.
6.
