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Name
First Name
Last Name
Phone Number
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Email
example@example.com
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Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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FILING STATUS
SINGLE
HEAD OF HOUSEHOLD
MARRIED FILING SEPARATE
MARRIED FILING JOINTLY
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EMPLOYMENT STATUS
Employed
Self Employed
OCCUPATION
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IP PIN IF APPLICABLE
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COPY OF TAXPAYER ID
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COPY OF TAXPAYER SS CARD
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COPY OF TAXPAYER W2s (CLEAR COPIES)
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COPY OF 1099
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COPY OF UTILITY BILL
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COPY OF DEPENDENT 1 SS CARD
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COPY OF DEPENDENT 2 SS CARD
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COPY OF DEPENDENT 3 SS CARD
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RELATIONSHIP TO DEPENDENTS
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ANY ADDITIONAL DOCUMENTS
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1095-A HEALTH INSURANCE MARKETPLACE
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DEPENDENT 1 BIRTHDATE
DEPENDENT 2 BIRTHDATE
DEPENDENT 3 BIRTHDATE
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BANK DEPOSIT ROUTING NUMBER
BANK DEPOSIT ACCOUNT NUMBER
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WHO REFERRED YOU? $50 Bonus
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