Taxpayer Information
Taxpayer's Information
(First Name)
(Initial)
(
Last Name)
(Soc. Sec. #)
Spouse's Information
(First Name)
(Initial)
(Last Name)
(Soc. Sec. #)
Street Address
(Zip)
(City)
(County)
(State)
Taxpayer's Phone #'s
(Home Number)
(Area Code ) - Number
(Work Number)
(Area Code ) - Number
Spouse's Phone #'s
(Home Number)
(Area Code ) - Number
(Work Number)
(Area Code ) - Number
General Information
Taxpayer
Spouse
Occupation
Birth Date
Age 65 or over
YES
YES
Blind
YES
YES
If died this year .. Date of death
Hope Education expense
(Include copy of 1099)
$
$
Lifetime Education expense
(Include copy of 1099)
$
$
Do you want $3 to go to the
Presidential Election Campaign?
YES
YES
Permanently & totally disabled
YES
YES
Have you previously filed a
Disability Statement?
YES
YES
Filing Status
Circle or Check the number that corresponds with your filing status.
1
= Single and you ARE Claimed as a Dependent on Another Person's Return.
1
= Single and you ARE NOT Claimed as a Dependent on Another Person's Return.
2
= Married Filing Joint Return. (Even if only one spouse had income)
3
= Married Filing Separate Returns. (Enter spouse name and Soc. Sec. # above)
Spouse is Itemizing
Taking Standard Deduction (Spouse is Taking Standard Deduction)
4
= Head of Household.
Qualifying Dependent:
Social Security Number:
5
= Qualifying Widow(er) with Dependent Child. ( Year Spouse Died
2006
2007
)