Tax Payer
Information
|
| First Name:___________________ Initial:___
Last Name:_______________________ |
| Social Security #:
______________________ |
| Occupation:___________________________ |
| Date of
Birth:__________________ |
| Street
Address:_________________________________ |
| City:_________________ State:____
Zip:____________ |
| Home
Telephone:______________________ |
| Work
Telephone:______________________ | |
Spouse
Information
|
| First Name:___________________ Initial:___
Last Name:_______________________ |
| Social Security #:
______________________ |
| Occupation:___________________________ |
| Date of
Birth:__________________ |
| Street
Address:_________________________________ |
| City:_________________ State:____
Zip:____________ |
| Home
Telephone:______________________ |
| Work
Telephone:______________________ | |
|
|
Salaries and
Wages
|
| W-2 |
Gross
Income |
Federal
Withholding |
FICA |
| 1 |
$ |
$ |
$ |
| 2 |
$ |
$ |
$ |
| 3 |
$ |
$ |
$ |
| 4 |
$ |
$ |
$ |
| 5 |
$ |
$ |
$ |
| W-2 |
Medical |
State
Withholding |
SDI |
| 1 |
$ |
$ |
$ |
| 2 |
$ |
$ |
$ |
| 3 |
$ |
$ |
$ |
| 4 |
$ |
$ |
$ |
| 5 |
$ |
$ |
$ | | |
|
|
Dependents
|
| Name:_________________________________ |
| Date of
Birth:__________________ |
| Social Security #:
_______________________ |
| Relationship:___________________________ |
| Months Lived at
Home:____________________ |
| Name:_________________________________ |
| Date of
Birth:__________________ |
| Social Security #:
_______________________ |
| Relationship:___________________________ |
| Months Lived at
Home:____________________ |
| Name:_________________________________ |
| Date of
Birth:__________________ |
| Social Security #:
_______________________ |
| Relationship:___________________________ |
| Months Lived at
Home:____________________ |
| Name:_________________________________ |
| Date of
Birth:__________________ |
| Social Security #:
_______________________ |
| Relationship:___________________________ |
| Months Lived at
Home:____________________ | |