Individual Tax Application

Tax Application

Complete this tax application using the information from the reference PDF. Preserve field labels and option sets as closely as possible. If the Questions don't apply to you put N/A.
Taxpayer Information
How did you hear about us

Other
Referral
Application Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hour MinutesAM/PM Option
Taxpayer Last Name
Taxpayer First Name
Taxpayer Middle Initial
Street Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Apartment/Unit #
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Birth Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Driver License State
Driver License Number
Spouse Information
Spouse Last Name
Spouse First Name
Spouse Middle Initial
Spouse Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Spouse Alternate Phone
Please enter a valid phone number.Format: (000) 000-0000.
Spouse Birth Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Spouse Driver License State
Spouse Driver License Number
Spouse Email
example@example.com
Residency and Prior Year Tax History
Filing Status
Residence State
Non-Residence State(s) where taxes were withheld but you were not a resident
Lived at above address 6 months or more
Did you file your taxes last year
If you filed last year, did you receive a refund
How did you file your taxes last year
Can you get a copy of your prior year’s return if needed
Need to file FORM 8862
Income, Coverage, Education, and Debt Eligibility
Did you have health insurance?
Was your insurance through an employer, state program, or Marketplace?
Number of jobs worked during the filing year
Did you receive unemployment income?
Did you attend college, night school, internet schooling, or post-secondary education?
Do you have a 1098-T form from your school?
Are you currently paying or do you owe student loans?
Do you own your home?
Do you owe for homebuyer credits?
Did you pay church tithes and offerings?
Do you owe student loans?
Do you owe back child support?
Do you owe the IRS?
Refund Preference and Direct Deposit
Preferred IRS refund method
Bank Name
Routing Number
Account Number
Direct deposit authorization signature
Prepaid card option – receive tax refund sooner
Printed check option – receive refund by printed check
Cash advance up to $1000 no interest today
Cash advance up to $7500 low interest today
Permission to put initials on tax return
Taxpayer Certification
Taxpayer certification – printed name
Taxpayer certification – signature
Taxpayer certification – date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Dependent Information
Dependent 1 First Name
Dependent 1 Last Name
Dependent 1 Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Dependent 1 Tax ID Number
Dependent 1 Relationship to You
Dependent 2 First Name
Dependent 2 Last Name
Dependent 2 Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Dependent 2 Tax ID Number
Dependent 2 Relationship to You
Dependent 3 First Name
Dependent 3 Last Name
Dependent 3 Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Dependent 3 Tax ID Number
Dependent 3 Relationship to You
Dependent 4 First Name
Dependent 4 Last Name
Dependent 4 Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Dependent 4 Tax ID Number
Dependent 4 Relationship to You
Did all your dependents stay with you at least 6 months?
Did you file these same dependents last year?
Child Care Provider Information
Child Care Provider 1 Name
Child Care Provider 1 Full Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Child Care Provider 1 Tax ID Number
Child Care Provider 1 Amount Paid
Child Care Provider 1 Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child Care Provider 2 Name
Child Care Provider 2 Full Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Child Care Provider 2 Tax ID Number
Child Care Provider 2 Amount Paid
Child Care Provider 2 Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Eligibility Record
Head of Household Eligibility
EIC Eligibility
Foster Child Eligibility
Eligibility Record Taxpayer Signature
Eligibility Record Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Tax Application

Taxpayer Information

Spouse Information

Residency and Prior Year Tax History

Income, Coverage, Education, and Debt Eligibility

Refund Preference and Direct Deposit

Taxpayer Certification

Dependent Information

Child Care Provider Information

Eligibility Record