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Tax year
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2
Your Name
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First Name
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3
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4
Date of Birth
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5
Email
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Occupation
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8
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9
Address
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Street Address
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City
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District of Columbia
Florida
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Idaho
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Indiana
Iowa
Kansas
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Ohio
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Tennessee
Texas
Utah
Vermont
Virginia
Washington
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Wisconsin
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State
Zip Code
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Afghanistan
Albania
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American Samoa
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Angola
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Argentina
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Aruba
Australia
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The Bahamas
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Bangladesh
Barbados
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Belgium
Belize
Benin
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Brazil
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Bulgaria
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Burundi
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Cameroon
Canada
Cape Verde
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Central African Republic
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China
Christmas Island
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Colombia
Comoros
Congo
Cook Islands
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Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
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Denmark
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Finland
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Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
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Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
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Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
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Guadeloupe
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Guyana
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Jordan
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Laos
Latvia
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Liberia
Libya
Liechtenstein
Lithuania
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Mali
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Mayotte
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Mongolia
Montenegro
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Myanmar
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Netherlands
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New Caledonia
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Nicaragua
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Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
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Saint Lucia
Saint Martin
Saint Pierre and Miquelon
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Samoa
San Marino
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Senegal
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10
Spouse Name
*
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First Name
Last Name
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11
Spouse's Social Security Number / ITIN
*
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Please do Not use Dashes. Ex: 123456789
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12
Spouse's Date of Birth
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Date
Month
Day
Year
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13
Spouse's Phone Number
Please enter a valid phone number.
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14
Spouse's Email
example@example.com
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15
Spouse's Occupation
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16
Are you claiming any dependents?
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YES
NO
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17
Enter your dependents here
Name
Date of Birth
Social Security
Relationship
1
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
2
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
3
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
4
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
5
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
1
2
3
4
5
Name
Row 0, Column 0
Date of Birth
Row 0, Column 1
Social Security
Row 0, Column 2
Relationship
Row 0, Column 3
Name
Row 1, Column 0
Date of Birth
Row 1, Column 1
Social Security
Row 1, Column 2
Relationship
Row 1, Column 3
Name
Row 2, Column 0
Date of Birth
Row 2, Column 1
Social Security
Row 2, Column 2
Relationship
Row 2, Column 3
Name
Row 3, Column 0
Date of Birth
Row 3, Column 1
Social Security
Row 3, Column 2
Relationship
Row 3, Column 3
Name
Row 4, Column 0
Date of Birth
Row 4, Column 1
Social Security
Row 4, Column 2
Relationship
Row 4, Column 3
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18
Do you have any expenses for child/elderly care?
YES
NO
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19
Provider's Name
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20
Provider's EIN or SSN
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21
Provider's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
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Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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22
Amount PAID to provider:
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23
Bank Info
Please enter Bank Account Number
Please enter Routing Number
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24
Do you own a business or farm, rental or royalty property, or are you an interest in a partnership, S-Corporation, Trust?
YES
NO
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25
Did you have any debts cancelled or forgiven?
YES
NO
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26
Do you or your spouse OWE IRS, CHILD SUPPORT, STUDENT LOANS, UNEMPLOYMENT?
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27
Did you or your spouse take money from your 401k?
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NO
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28
Did you or your spouse have any tuition expenses?
YES
NO
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29
Did you have health insurance with the Marketplace (OBAMACARE) at any time?
*
This field is required.
** If yes to last question, Please provide Form 1095-A
YES
NO
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30
Did you or your spouse sell any stocks last year?
YES
NO
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31
Do you own or rent?
Own
Rent
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32
Did you receive a federal tax last year?
YES
NO
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33
Are you a victim of identity theft?
YES
NO
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34
Documents
Please select the income items which pertain to you
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35
Documents
Please select the expense items which pertain to you
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36
Please upload driver's license or id and social security cards, and birth certificates for yourself and all children
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Max. file size
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37
Please Upload Documents Here (Including W2)
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38
CAN ANYONE ELSE CLAIM YOUR DEPENDENT?
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NO
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39
WERE ANY CREDITS DISALLOWED IN A PREVIOUS YEAR ?
YES
NO
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40
DID YOU PAY FOR MORE THAN HALF THE COSTS OF KEEPING UP A HOME FOR THE YEAR?
YES
NO
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41
DID YOUR CHILD LIVE WITH YOU MORE THAN 1/2 THE YEAR ?
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42
ARE YOUR DEPENDENTS A CITIZEN, RESIDENT, OR NATIONAL OF US?
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43
CAN YOU PROVIDE DOCUMENTATION IF ASKED FOR PROOF ?
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44
Tax Services Agreement
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45
Your Signature
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46
Date Signed
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47
Spouse Signature
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48
Date Signed
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