Taxes Request Form

Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Email

Date of Birth

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)

Spouse Name

First

Last

Spouse Occupation

Student, Teacher, Electrician, Realtor, Retired, etc.

Spouse Date of Birth

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

Dependent 1 Social Security Number

xxx-xx-xxxx

Dependent 1 Relationship

Son, Daughter, Mother, Father, etc.

Dependent 2 Name

First

Last

Dependent 2 Date of Birth

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

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

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

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

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

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?

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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