Please Complete the Form Below

Part I – Your Personal Information (If you are filing a joint return, enter your names in the same order as last year’s return)
1. Your first name
M.I.
Last name
Social Security Number
Daytime telephone number
Are you a U.S. citizen?
Yes No
2. Your spouse’s first name
M.I.
Last name
Social Security Number
Daytime telephone number
Is your spouse a U.S. citizen?
Yes No
3. Mailing address
Apt #
City
State
ZIP Code
4. Your Date of Birth
5. Your job title
6. Last year, were you:
b. Totally and permanently disabled Yes No
a. Full-time student  
Yes No
c. Legally blind
Yes No
7. Your spouse’s Date of Birth
8. Your spouse’s job title
9. Last year, was your spouse:
b. Totally and permanently disabled Yes No
a. Full-time student  
Yes No
c. Legally blind
Yes No
10. Can anyone claim you or your spouse as a dependent? Yes No Unsure
11. Have you, your spouse, or dependents been a victim of tax related identity theft or been issued an Identity Protection PIN?
Yes No
Part II – Marital Status and Household Information
1. As of December 31, 2020, what was your marital status?
Single (This includes registered domestic partnerships, civil unions, or other formal relationships under state law)
Married
a. If Yes, Did you get married in 2020?
 Yes No
b. Did you live with your spouse during any part of the last six months of 2020?
 Yes No
Divorced
Date of final decree
Legally Separated
Date of separate maintenance decree
Widowed
Year of spouse’s death
2. List the names below of
  • everyone who lived with you last year (other than your spouse)
  • anyone you supported but did not live with you last year
First Name (Do not enter your name or spouse’s name)
Last Name (Do not enter your name or spouse’s name)
Date of Birth
(mm/dd/yy)
Relationship to you
 Number of months lived in your home last year US Citizen Single or Married as of 12/31/20 Full-time Student last year Totally and Permanently Disabled

If you have additional dependents let your Tax Preparer know

Check appropriate box for each question in each section
Part III – Income – Last Year, Did You (or Your Spouse) Receive
Yes No Unsure Part III – Income – Last Year, Did You (or Your Spouse) Receive
1. Wages or Salary? (Form W-2) If yes, how many jobs did you have last year?
2. Tip Income?
3.  Scholarships? (Forms W-2, 1098-T)
Forms W-2 1098-T
4.  Interest/Dividends from: checking/savings accounts, bonds, CDs, brokerage? (Forms 1099-INT, 1099-DIV)
Forms 1099-INT 1099-DIV
5. Refund of state/local income taxes? (Form 1099-G)
6. Alimony income or separate maintenance payments?
7.  Self-Employment income? (Form 1099-MISC, 1099-NEC, cash, virtual currency, or other property or services)
Form 1099-MISC 1099-NEC
8.  Cash/check/virtual currency payments, or other property or services for any work performed not reported on Forms W-2 or 1099?
Cash Check
9.  Income (or loss) from the sale or exchange of Stocks, Bonds, Virtual Currency or Real Estate? (including your home) (Forms 1099-S,1099-B)
Forms 1099-S 1099-B
10. Disability income? (such as payments from insurance, or workers compensation) (Forms 1099-R, W-2)
Forms 1099-R W-2
11. Retirement income or payments from Pensions. Annuities, and or IRA? (Form 1099-R)
12. Unemployment Compensation? (Form 1099G)
13. Social Security or Railroad Retirement Benefits? (Forms SSA-1099, RRB-1099)
Forms SSA-1099 RRB-1099
14. Income (or loss) from Rental Property?
15. Other income? (gambling, lottery, prizes, awards, jury duty, virtual currency, Sch K-1, royalties, foreign income, other property or services, etc.) Specify  
Part IV – Expenses – Last Year, Did You (or Your Spouse) Pay
Yes No Unsure Part IV – Expenses – Last Year, Did You (or Your Spouse) Pay
1.  Alimony or separate maintenance payments? If yes, do you have the recipient’s SSN?
Yes No
2.  Contributions to a retirement account?
IRA 401K Roth IRA Other
3.  College or post secondary educational expenses for yourself, spouse or dependents? (Form 1098-T)
4.  Any of the following?
Medical & Dental (including insurance premiums)
Mortgage Interest (Form 1098)
Taxes (State, Real Estate, Personal Property, Sales)
Charitable Contributions
5.  Child or dependent care expenses such as daycare?
6.  For supplies used as an eligible educator such as a teacher, teacher’s aide, counselor, etc.?
7.  Expenses related to self-employment income or any other income you received?
8.  Student loan interest? (Form 1098-E)
Part V – Life Events – Last Year, Did You (or Your Spouse)
Yes No Unsure Part V – Life Events – Last Year, Did You (or Your Spouse)
1.  Have a Health Savings Account? (Forms 5498-SA, 1099-SA, W-2 with code W in box 12)
Forms 5498-SA 1099-SA W-2
2.  Have credit card or mortgage debt cancelled/forgiven by a lender or have a home foreclosure? (Forms 1099-C, 1099-A)
Forms 1099-C 1099-A
3. Adopt a child?
4. Have Earned Income Credit, Child Tax Credit or American Opportunity Credit disallowed in a prior year? If yes, for which tax year?
5. Purchase and install energy-efficient home items? (such as windows, furnace, insulation, etc.)
6. Receive the First Time Homebuyers Credit in 2008?
7. Make estimated tax payments or apply last year’s refund to this year’s tax? If so how much?
8. File a federal return last year containing a “capital loss carryover” on Form 1040 Schedule D?
9. Have health coverage through the Marketplace (Exchange)? [Provide Form 1095-A]
10. Receive an Economic Impact Payment (stimulus) in 2020?
Additional Information and Questions Related to the Preparation of Your Return
Additional Information
1. Provide an email address (optional) (this email address will not be used for contacts from the Internal Revenue Service)
2. Presidential Election Campaign Fund (If you check a box, your tax or refund will not change)
Check here if you, or your spouse if filing jointly, want $3 to go to this fund
You Spouse
3. If you are due a refund, would you like:
a. Direct deposit
Yes      No
b. To purchase U.S. Savings Bonds
Yes      No
c. To split your refund between different accounts
Yes      No
4. If you have a balance due, would you like to make a payment directly from your bank account? Yes No
5. Did you live in an area that was declared a Federal disaster area? Yes No If yes, where?
6. Did you, or your spouse if filing jointly, receive a letter from the IRS? Yes No
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Uploaded Files:

    Consent:
    I/we, the taxpayer, have read the above information.
    I/we hereby consent to the disclosure of tax return information described in the Global Carry Forward terms above and allow the tax return preparer to enter a PIN in the tax preparation software on my behalf to verify that I/we consent to the terms of this disclosure.
    Primary taxpayer printed name I authorize my Tax Preparer to enter the five number PIN I have choosen below. Date
    Secondary taxpayer printed name I authorize my Tax Preparer to enter the five number PIN I have choosen below. Date
    If you believe your tax return information has been disclosed or used improperly in a manner unauthorized by law or without your permission, you may contact the Treasury Inspector General for Tax Administration (TIGTA) by telephone at 1-800-366-4484, or by e-mail at complaints@tigta.treas.gov.