Are you a Are you a New Customer Returning Customer

Primary Taxpayer Name

Date of Birth

Marital Status Marital StatusSingleMarriedWidowed

Occupation

City,State,Zip

Preferred Contact Method Preferred Contact MethodEmailPhone

Best Phone Number

Email

Spouse Name

Spouse Date of Birth

Spouse Occupation

Spouse Address (if different)

Preferred Spouse Contact Method Preferred Spouse Contact MethodEmailPhone

Spouse Phone Number

Spouse Email

Can you be claimed as dependent by someone else? Can you be claimed as dependent by someone else? Yes No

Are you an active member or the spouse/dependent of an active member of the military? Are you an active member or the spouse/dependent of an active member of the military? Yes No

Would you like to donate $3 to the presidential campaign fund? Would you like to donate $3 to the presidential campaign fund? Yes No

Dependents* (or person living in your household) Dependents* (or person living in your household)012345

Dependent 1 Name

Months living in

Relationship

Date of Birth

Full Time Student? Full Time Student? Yes No

Disabled? Disabled? Yes No

Dependent 2 Name

Months living in

Relationship

Date of Birth

Full Time Student? Full Time Student? Yes No

Disabled? Disabled? Yes No

Dependent 3 Name

Months living in

Relationship

Date of Birth

Full Time Student? Full Time Student? Yes No

Disabled? Disabled? Yes No

Dependent 4 Name

Months living in

Relationship

Date of Birth

Full Time Student? Full Time Student? Yes No

Disabled? Disabled? Yes No

Dependent 5 Name

Months living in

Relationship

Date of Birth

Full Time Student? Full Time Student? Yes No

Disabled? Disabled? Yes No

Income From: Check all that apply Income From: Check all that apply Employer (W-2) Interest (1099-Int) Dividends (1099-Div) Stock or Mutual Fund sale(1099-B) N.A.

Check all that apply Check all that apply Misc. Income (1099-MISC) Foreign Income Social Security/Retirement Rental Property* Unemployment Other N.A.

Expenses From: Check all that apply Expenses From: Check all that apply Self Employment* Education Medical/Dental care N.A.

Expenses From: Check all that apply Expenses From: Check all that apply Rental Property N.A.

Credits and Deductions: Check all that apply. Did you or your spouse: Credits and Deductions: Check all that apply. Did you or your spouse: Donate cash or goods to a charity? Pay Child/Dependent Care expense? Make an IRA Contribution? Pay Property Taxes? Pay Student Loan interest? Have a Mortgage Payment? (1098) Pay Property Taxes? Make a major taxable purchase? N.A.

Miscellaneous: Check all that apply. Did you or your spouse: Miscellaneous: Check all that apply. Did you or your spouse: Sell a home? Pay/Receive alimony? Suffer catastrophic loss? Take an IRA or 401(k) distribution? Adopt a child? Have gambling winnings/losses? N.A.

Notes

I authorize TaxSmart Inc. to contact me to do a follow up regarding this submission using the contact information I provided: I authorize TaxSmart Inc. to contact me to do a follow up regarding this submission using the contact information I provided: Authorize