Educators Tax Services

First Name

Last Name

D.O.B.
(mm/dd/yy)

S.S.#
(000-00-000)

Relationship

Months in Home

Non - Dep

If you would like more information about our Tax services, please fill out the form below. If you prefer not to fill out this form online, click on the link below for a printable PDF version.

Click here to fill out our printable tax form

First Name:

Spouse's First Name:

M.I.:

Spouse's M.I.:

Last Name:

Spouses Last Name:

Social Security #:

- -

Spouse's SS#:

- -

Present Address:

City:

State:

Zip:

E-Mail Address:

Filing Status:

Single Married Filing Jointly Married Filing Separately
Head of Household Qualifying Widow(er)

*If you selected Head of Household and have dependents, list the name and social security number of the qualifying child that lives with you.

Name: SS#: - -

Dependents / Non-Dependents Qualifying for Child Care and / or EIC
*If any dependent(s) listed below are non dependents, then mark an "X" in the column listed "Non Dep"

If you are claiming as a dependent a child who did not live with you, you must check the following documents that substantiate this claim: ( ) Pre-1985 divorce or separation agreement ( ) Signed form 8332 ( ) Post-1984 divorce or separation agreement WITHOUT CONDITIONS ( ) Signed Form 2120

Birthdate: (mm/dd/yyyy)

/ /

Spouse's Birthdate:
(mm/dd/yyyy)

/ /

Occupation:

Spouse's Occupation:

Daytime Phone:

- -

Daytime Phone:

- -

Evening Phone:

- -

Evening Phone:

- -

Cell Phone:

- -

Cell Phone:

- -

State of Residence:

State of Part -Year Resdidence:

2nd State of Part-Year Residence:

Did you or your spouse receive income from any of the following sources?			Did you or our spouse sell or dispose of any of the following?
Yes	No		Yes	No
		Wages			Stocks or Mutual Funds
		Tips			Personal Residence
		Interest or Dividends
		Social Security / Railroad benefits	Did you or your spouse:
		Pension / Annuity / IRS / Retirement	Yes	No
		Unemployment			Have a mortgage
		Alimony			Have medical expenses
		Self Employment / Operating a Business			Make charitable contributions
		Gambling Winnings			Have unreimbursed expenses for a job
		Rent / Royalties / Misc. Income			Have job-related moving expenses
		Stocks / Bonds			Pay any federal or state estimate taxes
		Proceeds from Real Estate Transaction			Contribute to IRA / SEP / Keogh / Simple Plan
		Partnership / Corporation			Get claimed on someone else's return
		Estate Trust Fund			Pay child or dependent care
		State tax refund from last year			Pay education or tuition expenses
					Pay Interest on education loans
					Have K-12 Educator Expenses
					Have school expenses for K-12 children

**If you received an IRA distribution, and nondeductable contributions were made, provide the balance of all IRA accounts as of the end of 2003 You must include a copy of your federal and state return from last year