Customer Data Sheet
Integrity Taxes 365
For the year Jan. 1- Dec. 31, 20__ , or other tax year beginning
Name (As it appears on your Social Security Card)
*
First Name
Taxpayer Last Name
Soc. Sec. No.
*
Name (If Married and Filing Jointly or Separately)
First Name
Spouse Last Name
Soc. Sec. No.
I am interested in having the fee deducted from my refund
*
Please Select
Yes
No, I will pay with cash or credit card
Address
*
Street Address
City
Is this City or County?
State / Province
Postal / Zip Code
Tax Payer's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Tax Payer's Email
*
example@example.com
Birthdate
*
-
Month
-
Day
Year
Occupation
*
Are You Married?
*
Please Select
Yes, we live together
Yes, we live separately
No
Spouse Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Spouse Email
example@example.com
Spouse Birthdate
/
Month
/
Day
Year
Spouse Occupation
Dependents (list youngest first)
Rows
Name (First, Last)
Birthdate
Social Security Number
Months Lived With You?
Dependent
Dependent
Dependent
Dependent
Dependent
Childcare Provider's Name
SSN or EIN
Address
Provider's Address
Street Address Line 2
City
State / Province
ZIP
Amount Paid
Check The Income Items Which Pertain To You
*
State Tax Refund
Wage Statement W-2's Unemployment
Pension, Retirement Income
Rental Income K-1 from any source
1099-Rs Social Security Benefits Lottery or Gambling Winnings Alimony Received
Interest Income
Dividends Self-Employed Business Income Tip Income
Sale of home
1099-A/1099-C
Did you sell any stock, real estate, business autos or business equipment?
1099-MISC.
Dependents: (List youngest first) Name: (first name, last name)
Phone: (Home) Married: Yes No
Income from any state other than Maryland List states_____________
Other
To the best of my knowledge this information is correct and includes all income, deductions, and other information necessary for preparation of the year's income tax return.
*
Below For Preparer Use Only: Preparer Number on Receipt
SSN & Name Verified
Preparer Number
SSN & Name Verified
All forms signed
ID
For Preparer Use Only: Preparer Number ol Receipt
ID#
Receipt #
ID
Accepted/Declined
Exp. Date
/
Month
/
Day
Year
Date
ID#
Issue Date
/
Month
/
Day
Year
Date
Exp. Date
Issue Date
/
Month
/
Day
Year
Date
Submit
Should be Empty: