Please fill out the details exactly as shown on your documents.
Name (First, Middle, Last)
Social Security Number
Date of Birth (MM/DD/YYYY)
Driver’s License #
State
Issue Date
Expiry Date
Occupation
E-mail Address
Can anyone claim you as dependent? YesNo
Were you married as of Dec 31st, 2025? YesNo
If married, lived together? YesNo
Address
City
Zip
Phone
Spouse Name (First, Middle, Last)
If separated, date (MM/DD/YYYY)
Dependent Name (First, Middle, Last)
Date of Birth
Social Security #
Relationship
Months Lived
Can anyone else claim the dependent(s) listed above? YesNo
Number of W2(s)
1099-R
K-1 S-Corp/Estate
1099-INT (Interest)
SSA-1099
Alimony Received
1099-DIV (Dividend)
1099-B
Railroad Retirement
1099-MISC/NEC
Rental Income
1099-C Debt Cancel
Self-employed?YesNo If yes, type?
I certify that all the information provided is true and accurate to the best of my knowledge.
How would you like to sign? Draw Signature Type Signature
Draw below:
Type your full name:
Date
Spouse Signature (Type)
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