Last 4 SSN # Number* DL# Numbe* 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
SPOUSE SSN# NumberDate 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 CodePhone Number
First NameLast Name Last 4 of SSN# NumberDate Relationship Please Select Daughter Son Niece Nephew Tuition/dependent care $ Number Disabled YesNo
First NameLast NameNumberDate Please Select Daughter Son Niece Nephew Tuition/dependent care $ NumberYesNo
First NameLast NameNumberDate Please Select Daughter Son Niece Nephew NumberYesNo
I Hereby certify that the information provided on this form is correct to the best of my ability and therefore authorize Smith & Associtaes Tax Solutions LLC to prepare and/or electronically file my Tax Return.