What year(s) are you filing2018 20192020
First Economic Stimulus Payment $ Amount Second Economic Stimulus Payment $ Amount
TaxpayerSSN# Number* DOB Date* DL# Number* State Please Select AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY * ISS Date Date EXP Date Date Occupation * Phone Area Code Phone Number
SPOUSE SSN# Number DOB Date DL# Number State Please Select AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY ISS Date Date EXP Date Date Occupation Phone Area Code Phone Number
First Name Last Name SSN# Number DOB Date Relationship Please Select Daughter Son Niece Nephew Tuition/dependent care $ Number Disabled Yes No
First Name Last Name SSN# Number DOB Date Relationship Please Select Daughter Son Niece Nephew Tuition/dependent care $ Disabled Yes No
Medical Insurance $ Number Dental $ Number Vision $ Number
I hereby certify that the above statements are true and correct to the best of myknowledge. I understand that a false statement may disqualify me for benefits.
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Taxpayer Signature Date Spouse Signature Date