Individual Tax Questionnaire
Tax Year
*
Did you file with us last year?
*
Yes
No
Taxpayer's Name
*
First Name
Middle Name
Last Name
Social Security Number
*
DOB
*
-
Month
-
Day
Year
Date
Occupation
*
Cell Phone Number
*
-
Area Code
Phone Number
Home Phone Number
-
Area Code
Phone Number
Email
*
example@example.com
Mailing Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
County
*
Do you have an IP PIN (Identity Protection PIN)
*
Yes
No
What is your IP PIN
Are you a U.S Citizen or Green Card Holder?
*
Yes
No
Filing Status (Please check one):
*
Single
Head of Household
Married Filing Joint
Married Filing Separate (if separated, please provide spouse's information below)
Qualifying Widow(er) with Child
Are you currently serving in the military?
*
Yes
No
Are you permanently disabled?
*
Yes
No
Type option 4
Are you a full-time student?
*
Yes
No
Are you legally blind?
*
Yes
No
Can you be claimed as a dependent on another taxpayer's return?
*
Yes
No
Do you want $3 to go to the Presidential Campaign Fund?
*
Yes
No
How did you hear about Brown's FCA?
*
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Spouse's Name
*
First Name
Middle Name
Last Name
Spouse's Social Security Number
*
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Next
Spouse's DOB
*
-
Month
-
Day
Year
Date
Spouse's Occupation
*
Cell Phone Number
*
-
Area Code
Phone Number
Home Phone Number
-
Area Code
Phone Number
Email
*
example@example.com
Is your spouse currently serving in the military?
*
Yes
No
Did you or your spouse receive a W-2 Form?
*
Yes
No
If yes, please upload W-2 Form(s)
Browse Files
Cancel
of
Did you or your spouse receive Form 1099?
*
Yes
No
If yes, please upload Form 1099
Browse Files
Cancel
of
Did you or your spouse receive Unemployment Compensation?
*
Yes
No
If yes, please upload Form 1099-G
Browse Files
Cancel
of
Did you, your spouse, or dependent receive Social Security Income?
*
Yes
No
If yes, please upload Form 1099-SA
Browse Files
Cancel
of
Did you or your spouse receive Miscellaneous Income?
*
Yes
No
Did you or your spouse receive any self-employment income
*
Yes
No
Did you or your spouse sell any stocks?
*
Yes
No
Did you, your spouse, or dependent receive Health Insurance through the Marketplace?
*
Yes
No
If yes, please upload Form 1095-A
Browse Files
Cancel
of
Did you, your spouse, or dependent receive any scholarships?
*
Yes
No
Do you or your spouse have any college or post-secondary education expenses?
*
Yes
No
Do you or your spouse have any student loan interest?
*
Yes
No
Did you or your spouse receive any interest or dividends from any accounts, bonds, or brokerage
*
Yes
No
Do you or your spouse have any digital cash or assets?
*
Yes
No
Did you or your spouse purchase a home last year?
*
Yes
No
Did you or your spouse sell a home or any other properties?
*
Yes
No
Did you or your spouse sell a home or any other properties?
*
Yes
No
Do you or your spouse own rental properties
*
Yes
No
Do you or your spouse own a business?
*
Yes
No
If yes, please provide the EIN
Do you or your spouse have any expenses for supplies used as an eligible educator such as teacher, teacher's aide, counselor, etc?
*
Yes
No
Do you or your spouse have any contributions to any retirement accounts?
*
Yes
No
Have your or your spouse Earned Income Credit, Child Tax Credit, or American Opportunity credit disallowed in a prior year?
*
Yes
No
Did you or your spouse receive any refund from state/local income taxes?
*
Yes
No
Did you or your spouse purchase and install energy-efficient home items?
*
Yes
No
Did you or your spouse live in an area that was declared a Federal Disaster Area?
*
Yes
No
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Dependent Information
Dependent #1
First Name
Last Name
DOB
-
Month
-
Day
Year
Date
SSN
# of months in home (This year)
Relationship
Student Status
Full Time
Part time
Disabled?
Yes
No
Dependent #2
First Name
Last Name
DOB
-
Month
-
Day
Year
Date
SSN
# of months in home (This year)
Relationship
Student Status
Full Time
Part time
Disabled?
Yes
No
Dependent #3
First Name
Last Name
DOB
-
Month
-
Day
Year
Date
SSN
# of months in home (This year)
Relationship
Student Status
Full Time
Part Time
Disabled?
Yes
No
Back
Next
Did you receive a W-2 Form?
*
Yes
No
If yes, please upload W-2 Form(s)
Browse Files
Cancel
of
Did you receive Form 1099?
*
Yes
No
If yes, please upload Form 1099
Browse Files
Cancel
of
Did you receive Unemployment Compensation?
*
Yes
No
If yes, please upload Form 1099-G
Browse Files
Cancel
of
Did you or your dependent (if applicable) receive any Social Security Income?
*
Yes
No
If yes, please upload Form 1099-SA
Browse Files
Cancel
of
Did you receive Miscellaneous Income?
*
Yes
No
Did you receive any self-employment income
*
Yes
No
Did you sell any stocks?
*
Yes
No
If yes, please upload Form 1099-B
Browse Files
Cancel
of
Did you receive any scholarships?
*
Yes
No
Do you have any college or post-secondary education expenses?
*
Yes
No
Do you have any student loan interest?
*
Yes
No
Did you or dependent (if applicable) receive Health Insurance through the Marketplace?
*
Yes
No
If yes, please upload Form 1095-A
Browse Files
Cancel
of
Do you have any expenses for supplies used as an eligible educator such as teacher, teacher's aide, counselor, etc?
*
Yes
No
At any time during the tax year, did you: (a) receive (as a reward, award, or payment for property or services); or (b) sell, exchange, or otherwise dispose of a digital asset (or a financial interest in a digital asset)?
*
Yes
No
Do you have any digital cash or assets?
*
Yes
No
Do you have any contributions to any retirement accounts?
*
Yes
No
Have you earned income credit, child tax credit or american opportunity credit disallowed in a prior year?
*
Yes
No
Did you receive any refund from state/local income taxes?
*
Yes
No
Did you sell a home or any other properties?
*
Yes
No
Did you purchase a home last year?
*
Yes
No
Do you own a business?
*
Yes
No
If yes, please provide the EIN
Do you own rental properties
*
Yes
No
Did you purchase and install energy-efficient home items?
*
Yes
No
Did you live in an area that was declared a Federal Disaster Area?
*
Yes
No
Back
Next
Please upload a form of government identification
*
Browse Files
Cancel
of
Check here if you would like to receive direct deposit if you are due a refund
Bank Account Type
*
Checking
Savings
N/A
Routing #
*
Account #
*
Bank Name
*
By signing I declare that all information provided on this sheet is true and accurate to the best of my knowledge.
*
Date
*
-
Month
-
Day
Year
Submit
Should be Empty: