DEPENDENT #1 NAME: First Name Last Name RELATIONSHIP: Relationship DATE OF BIRTH: Date of Birth SOCIAL SECURITY NUMBER: SSN MONTHS LIVED WITH YOU: months lived with you FULL TIME STUDENT?YES NO DID YOU PROVIDE MORE THAN HALF OF THE SUPPORT? YES NO
DEPENDENT #2 NAME: First Name Last Name RELATIONSHIP: Relationship DATE OF BIRTH: Date of Birth SOCIAL SECURITY NUMBER: SSN MONTHS LIVED WITH YOU: months lived with you FULL TIME STUDENT? YES NO DID YOU PROVIDE MORE THAN HALF OF THE SUPPORT? YES NO
DEPENDENT #3 NAME: First Name Last Name RELATIONSHIP: Relationship DATE OF BIRTH: Date of Birth SOCIAL SECURITY NUMBER: SSN MONTHS LIVED WITH YOU: months lived with you FULL TIME STUDENT? YES NO DID YOU PROVIDE MORE THAN HALF OF THE SUPPORT? YES NO
DEPENDENT #4 NAME: First Name Last Name RELATIONSHIP: Relationship DATE OF BIRTH: Date of Birth SOCIAL SECURITY NUMBER: SSN MONTHS LIVED WITH YOU: months lived with you FULL TIME STUDENT? YES NO DID YOU PROVIDE MORE THAN HALF OF THE SUPPORT? YES NO
DEPENDENT #5 NAME: First Name Last Name RELATIONSHIP: Relationship DATE OF BIRTH: Date of Birth SOCIAL SECURITY NUMBER: SSN MONTHS LIVED WITH YOU: months lived with you FULL TIME STUDENT? YES NO DID YOU PROVIDE MORE THAN HALF OF THE SUPPORT? YES NO
If yes, that you or your spouse contributed to an IRA, please provide the amounts below.Taxpayer $ Amount to ROTH IRA Taxpayer $ Amount to Traditional IRA Spouse $ Amount to ROTH IRA Spouse $ Amount to Traditional IRA
If yes, how much additional HSA was contributed?Taxpayer $ Amount Spouse $ Amount
PLEASE LIST FEDERAL ESTIMATED PAYMENT AMOUNT(S) AND DATE(S) PAID BELOW.Federal Payment #1 $ Amount Date Paid Date Federal Payment #2 $ Amount Date Paid Date Federal Payment #3 $ Amount Date Paid Date Federal Payment #4 $ Amount Date Paid Date
PLEASE LIST STATE ESTIMATED PAYMENT AMOUNT(S) AND DATE(S) PAID BELOW. IF ADDITIONAL STATES, PLEASE LET US KNOW. Please Select NC SC Payment #1 $ Amount Date Paid Date Payment #2 $ Amount Date Paid Date Payment #3 $ Amount Date Paid Date Payment #4 $ Amount Date Paid Date