TAXPAYER INFORMATION SPOUSE INFORMATION
* First Name: ____________________________ * First Name: _______________________
* Last Name: ____________________________ * Last Name: _______________________
* S.S. #: ________________________________ * S.S. #: ___________________________
* Occupation: ____________________________ * Occupation: ______________________
* Date of Birth: ___________________________ * Date of Birth: _____________________
* Street Address: __________________________ * Street Address: ____________________
* City: __________________________________ * City: ____________________________
* State: _______________ Zip: ______________ * State: ____________ Zip: ___________
* County: _______________________________ * County: __________________________
* Home Telephone: ________________________ * Home Telephone: __________________
* Cell Phone: _____________________________ * Cell Phone: _______________________
* Work Phone: _____________________________ * Work Phone: ______________________
* Email Address: ___________________________ * Email Address: ____________________
* State of Residence as of 12/31/08: ____________
Full Year _______ Partial Year __________
Would you like to file your return electronically? (Free) Yes __________ No ______________
Are you interested in Direct Deposit of a refund? Yes _________________ No ______________
If yes, please include the following:
Bank Routing Number: ______________________________________________________(9 digits)
Bank Account Number: _____________________________________________________________
Type of Bank Account: Savings __________________ Checking_____________________
Name of Financial Institution: ________________________________________________________
FILING STATUS
_______ Single _______ Married ______ Head of Household ______ Married Filing Separate
DEPENDENT - CHILDREN AND DEPENDENT INFORMATION
Name: __________________________________ Name: ______________________________
Date of Birth: _____________________________ Date of Birth: _________________________
Social Security # __________________________ Social Security # ______________________
Relationship: _____________________________ Relationship: _________________________
Months Lived At Home: _____________________ Months Lived At Home: _________________
Student: Yes ___________ No ______________ Student: Yes __________ No ___________
Childcare Expenses (If Applicable)
Child's Name:_____________________________________________________________________
Expense Amount: __________________________________________________________________
Childcare Provider: _________________________________________________________________
Providers Address & Phone Number: ___________________________________________________
Providers Tax ID #: ________________________________________________________________
Child's Name: _____________________________________________________________________
Expense Amount: __________________________________________________________________
Childcare Provider: _________________________________________________________________
Providers Address & Phone Number: ___________________________________________________
Providers Tax ID #: _________________________________________________________________
ITEMIZED DEDUCTIONS (Use this section if you own a home and pay a mortgage)
Medical and Dental Expenses Taxes Paid
Insurance Premiums (Net): __________________ State and Local Income Tax: ______________
Doctors, Dentists, etc.: ______________________ Real Estate Taxes- Residence: _____________
Other Medical costs paid: ___________________ Real Estate Taxes- Other Property: __________
Pharmacy: _______________________________ Auto Excise Tax: ________________________
Personal Property Taxes: __________________
Interest Paid - Attach 1098 Forms Other Taxes: ___________________________
Home Mortgage Interest Paid (1st): ____________ Did you use a schedule A in 2006? ___________
Home Mortgage Interest Paid (2nd): ___________
Contributions - Attach Details
Contributions by cash or check: _______________
Contributions by other than cash: _____________
(PLEASE PROVIDE DETAILS IN ADDITIONAL INFORMATION)
OTHER INFORMATION
Amount of rent paid in 2007: ________________________________________________________
Landlord's Name and Phone Number: _________________________________________________
Landlord's Address: ________________________________________________________________
