Old Tax Form
Filing Status
Single
Head of Household
Married Filing Separate
Married Filing Joint
Qualifying Widower
Taxpayer Information
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Social Security Number
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
Are you a full-time student?
Yes
No
Are you totally and permanently disabled?
Yes
No
Spouse Information
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Social Security Number
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
Are they a full-time student?
Yes
No
Are they totally and permanently disabled?
Yes
No
Are they your dependent?
Yes
No
Dependents
Enter your dependents here
Rows
Name
Date of Birth
SSN
Relationship
1
2
3
4
5
6
Does you, your spouse, and your dependents have health insurance within 12 months last year? If yes, who covers for it?
Rows
Yes/No
Employer
Spouse Ins
Exchange/ Marketplace
Direct with Insurer
Medicare
Medicaid
Taxpayer
Yes
No
Spouse
Yes
No
Dependent 1
Yes
No
Dependent 2
Yes
No
Dependent 3
Yes
No
Dependent 4
Yes
No
Dependent 5
Yes
No
Tax Related Questions
Employment Status
Employed
Unemployed
Self-employed
Does your dependents have tuition expenses?
Yes
No
Do you have any expenses for child care?
Yes
No
Do you have your own home?
Yes
No
Do you have documents that shows you paid for property taxes?
Yes
No
Did you sell any stock?
Yes
No
Did you take money from your 401?
Yes
No
Did you have health insurance through the Marketplace? Include 1095-A
Yes
No
Do you have mortgage interest?
Yes
No
Do you have real estate tax?
Yes
No
Did you receive an IP PIN Number?
If yes please include number
Expenses
Please fill-out the information within the current year only.
General Expenses
Rows
Amount
Medical Expenses
Dental Expenses
Insurance Premiums paid
Long Term Care Premiums
Prescription Drugs and Medications
Home Mortgage
Investment Interest
Cash Contributions
Non-Cash Contributions
Unreimbursed Business Expenses
Union Dues
Tax Preparation Fees
Investment Expenses
Total Expenses
Additional comments
Acknowledgment & Signature
I confirmed that all information I entered here is accurate and true.
I allow Routt Insurancel to capture my sensitive data like personal id, government id, and other information.
I have read the terms and conditions and privacy policy of Routt Insurance
By signing below, you acknowledge that you have read and understood your responsibilities and our responsibilities in doing this tax return.
Date Signed
-
Month
-
Day
Year
Date
Taxpayer Signature
Date Signed
-
Month
-
Day
Year
Date
Spouse Signature
Print
Submit
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