Customer Data Sheet

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 NameTaxpayer Last Name
Soc. Sec. No.*
Name (If Married and Filing Jointly or Separately)

First NameSpouse Last Name
Soc. Sec. No.
I am interested in having the fee deducted from my refund*
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.
Tax Payer's Email*
example@example.com
Birthdate*

MonthDayYear
Occupation*
Are You Married?*
Spouse Phone Number
Please enter a valid phone number.
Spouse Email
example@example.com
Spouse Birthdate

MonthDayYear
Spouse Occupation

Dependents (list youngest first)

Childcare Provider's Name
SSN or EIN
Address

Provider's Address

Street Address Line 2

CityState / Province

ZIP
Amount Paid
Check The Income Items Which Pertain To You*

State Tax RefundWage Statement W-2's UnemploymentPension, Retirement IncomeRental Income K-1 from any source1099-Rs Social Security Benefits Lottery or Gambling Winnings Alimony ReceivedInterest IncomeDividends Self-Employed Business Income Tip IncomeSale of home1099-A/1099-CDid 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 NoIncome 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. *

Clear
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

MonthDayYear
Date
ID#
Issue Date

MonthDayYear
Date
Exp. Date
Issue Date

MonthDayYear
Date
Should be Empty: