CLIENT INFORMATION:

First Name:     MI:     Last Name:

Date of Birth: mm/dd/yyyy

Social Security Number:

Current Address:

Occupation:

SPOUSE INFORMATION:

First Name:     MI:     Last Name:

Date of Birth: mm/dd/yyyy

Social Security Number:

Current Address:

Occupation:

CONTACT INFORMATION

Work Phone:

Home Phone:

Cell Phone:

Email:

Please contact me: Work Home Cell

DEPENDANT INFORMATION

Dependant (1) Name:

Social Security Number:     Date of Birth: mm/dd/yyyy

Dependant (2) Name:

Social Security Number:     Date of Birth: mm/dd/yyyy

Dependant (3) Name:

Social Security Number:     Date of Birth: mm/dd/yyyy

Dependant (4) Name:

Social Security Number:     Date of Birth: mm/dd/yyyy

CHILD CARE INFORMATION

Day Care Provider Name:

Tax ID Number:     Amount: $

Address:

Phone:

Prior Year State Tax Refund: $

Educator Expenses: $

Student Loan Interest: $

Tuition and Fees: $

SCHEDULE A (ITEMIZED DEDUCTIONS)

Mortgage Interests: $    Property Taxes: $

Health Insurance Premium: $    Dental Insurance Premium: $

Eye/Optical Premium: $

Prescriptions: $    Co pays: $

Medical Mileage:

Purchase of New Vehicle: $    Vehicle Property Taxes: $

Computer Purchase: $    Cell Phone Purchase: $

Cash Contributions: $

Tithes/Offerings: $    Charity: $

Non-Cash Contributions: $ Charity (with receipt over $500)

EDUCATION

Class:

Training:

Books:

BUSINESS EXPENSES RELATED TO JOB

Moving Expenses:
Storage: $  Travel: $  Truck Rental: $