2023 Prillerman & Associates/ HILL N HILL Associates Personal Information Sheet
Primary Name
*
First Name
Last Name
Did you book an appointment to have your taxes prepared in that time slot? If yes then what date and time?
*
Appointment date and time
SSN
*
Numbers (no dashes)
Date Of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Filing Status
*
Please Select
Single
Married jointly
Married separately
Head of Household
Phone Number
*
-
Area Code
Phone Number
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
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
E-mail
*
Direct Deposit Information (Bank Name, Routing and Account number
*
Bank Name and Routing and Account Number
Additional Comments
Did Mica file your 2022 taxes?
*
Please Select
Yes
No
Drivers License number, Issue and Exp date
*
Number
Issue Date and Exp Date
Did the IRS issue either you and/or your dependent an IP PIN # ?
*
Please Select
Yes
No
If yes, type it here, if no, type N/A:
*
IP Pin number
Did you have Marketplace Health Insurance through healthcare.gov in 2023, if yes please attach the 1095-A?
*
Please Select
Yes
Yes,partial year
No
Spouse Information
*Only complete if you are filing Married Jointly or Married filing Separate.
Spouse Name
First Name
Last Name
SSN
Numbers (no dashes)
Date Of Birth
-
Month
-
Day
Year
Date Picker Icon
Spouse Driver's License, Issue and Exp Date
Do you or your spouse owe the IRS, State or any government agency?
*
Please Select
Yes
No
Dependents
Dependent 1
First Name
Last Name
SSN
Numbers (no dashes)
Date Of Birth
-
Month
-
Day
Year
Date Picker Icon
Relationship
Day Care Expenses
Please Select
Yes
No
Dependent 2
First Name
Last Name
SSN
Numbers (no dashes)
Date Of Birth
-
Month
-
Day
Year
Date Picker Icon
Relationship
Day Care Expenses
Please Select
Yes
No
Dependent 3
First Name
Last Name
SSN
Numbers (no dashes)
Date Of Birth
-
Month
-
Day
Year
Date Picker Icon
Relationship
Day Care Expenses
Please Select
Yes
No
Dependent 4
First Name
Last Name
SSN
Numbers (no dashes)
Date Of Birth
-
Month
-
Day
Year
Date Picker Icon
Relationship
Day Care Expenses
Please Select
Yes
No
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General Information
Did you or any of your dependents attend college in 2023?
*
YES
NO
If YES, What is the name of the college and please attach the 1098-T at the end.
Name of College
Income Information
Have you received all W-2's from all employers?
*
YES
NO
Did you start a new business or purchase any rental property during the past year?
*
YES
NO
Did you or your spouse receive Unemployment Income?
*
YES
NO
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Itemized Deductions
Cash donations
*
YES
NO
Real estate and personal property taxes paid
*
YES
NO
Prescription medications
*
YES
NO
Medical mileage
*
YES
NO
Mortgage Interest statement
*
YES
NO
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Next
I.D. Documents
I.D. Verification Upload
Cancel
of
Tax Documents
*
Tax Documents Upload
Cancel
of
Signature
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