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Name
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First
Last
Address
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Address Line 1
Address Line 2
City
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District of Columbia
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Texas
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Virginia
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Zip Code
Phone
*
Email
*
Date of Birth
*
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Occupation
*
Student, Teacher, Electrician, Realtor, Retired, etc.
Social Security Number
*
xxx-xx-xxxx
Relationship Status
*
Single
Married
Divorced
Filing Status (select best option; to maximize returns, this may be adjusted prior to filing)
*
Single
Married Filing Jointly
Married Filing Separately
Head of Household
Qualifying Widow(er) with Dependent Child
I don’t know
Spouse Name
*
First
Last
Spouse Occupation
*
Student, Teacher, Electrician, Realtor, Retired, etc.
Spouse Date of Birth
*
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Spouse Social Security Number
*
xxx-xx-xxxx
Do you have any Dependents?
*
Yes
No
I don’t know
Number of Dependents
Dependents:
0
Dependent 1 Name
*
First
Last
Dependent 1 Date of Birth
*
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Dependent 1 Social Security Number
*
xxx-xx-xxxx
Dependent 1 Relationship
*
Son, Daughter, Mother, Father, etc.
Dependent 2 Name
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First
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Dependent 2 Date of Birth
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Dependent 2 Social Security Number
*
xxx-xx-xxxx
Dependent 2 Relationship
*
Son, Daughter, Mother, Father, etc.
Dependent 3 Name
*
First
Last
Dependent 3 Date of Birth
*
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Dependent 3 Social Security Number
*
xxx-xx-xxxx
Dependent 3 Relationship
*
Son, Daughter, Mother, Father, etc.
Dependent 4 Name
*
First
Last
Dependent 4 Date of Birth
*
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1922
1921
1920
Dependent 4 Social Security Number
*
xxx-xx-xxxx
Dependent 4 Relationship
*
Son, Daughter, Mother, Father, etc.
Dependent 5 Name
*
First
Last
Dependent 5 Date of Birth
*
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1928
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1926
1925
1924
1923
1922
1921
1920
Dependent 5 Social Security Number
*
xxx-xx-xxxx
Dependent 5 Relationship
*
Son, Daughter, Mother, Father, etc.
Dependent 6 Name
*
First
Last
Dependent 6 Date of Birth
*
MM
1
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6
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8
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2015
2014
2013
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2011
2010
2009
2008
2007
2006
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1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Dependent 6 Social Security Number
*
xxx-xx-xxxx
Dependent 6 Relationship
*
Son, Daughter, Mother, Father, etc.
Dependent 7 Name
*
First
Last
Dependent 7 Date of Birth
*
MM
1
2
3
4
5
6
7
8
9
10
11
12
DD
1
2
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2020
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2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
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1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
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1972
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1968
1967
1966
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1941
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1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Dependent 7 Social Security Number
*
xxx-xx-xxxx
Dependent 7 Relationship
*
Son, Daughter, Mother, Father, etc.
Do you have an Active Business Entity?
*
Yes
No
I don’t know
Business Name and Tax ID or Employer Identification Number (EIN)
*
Your Business Name, ID: xxxxxxxxxxx
Business Address
*
Vehicle(s): Year, Make, Model
Example: 2024 Tesla Model Y, 2018 Ford Explorer, etc.
Did you receive a Form 1095-A for your health insurance plan?
*
Yes
No
I don't know
If you at any point during the tax year had an Affordable Care Act plan, you should have received this form. Contact your Marketplace if you have not recieved this form yet.
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