NAME -​

ADDRESS-

PHONE AND CELL-

EMAIL ADDRESS-

OCCUPATION-

FILING STATUS - SINGLE, MARRIED ETC.

DEPENDANTS-

SS #

DRIVERS LICENSE #

FEES TO BE  DEDUCTED YES OR NO

CHECK, DIRECT DEPOSIT OR MONEY PUT ON A AMERICAN EXPRESS CARD

MAKE SURE I HAVE TOTALS FOR MEDICAL IF YOU ARE PAYING FOR YOUR OWN INSURANCE

​ANY QUESTIONS FEEL FREE TO CALL ME FROM 12-12

PLEASE FILL OUT, PRINT AND INCLUDE THIS FORM WHEN DROPPING OFF YOUR TAXES

FILL OUT ONE FOR EACH ADULT  AND DEPENDANT