Your Full Name:* Email ID:* Phone Number:* AGE:* Are you Married?: * Are you Married? Yes No Are you filing Head of Household?: * Are you filing Head of Household? Yes No Are you a qualifying surviving spouse?: * Are you a qualifying surviving spouse? Yes No

Can someone claim you as a dependent on their tax return?: * Can someone claim you as a dependent on their tax return? Yes No Number of dependents:* Number of dependents under 13 who receive child care: * Number of dependents 17 or younger: * Number of dependents in school full-time age 18 to 23: *

Taxable wages: * Federal withholdings: * State withholdings: * Unemployment income: * Business profit/loss: * Interest: * Long-term gains/losses: * Short-term gains/losses: * IRA/pension distributions: * Dividends: * Alimony received: * Miscellaneous income: * Social security benefits: *

Medical expenses paid: * Real estate tax paid: * Mortgage interest paid: * Cash & check charitable contributions: * Noncash charitable contributions: * Unreimbursed employee expenses: *

Are you or your child attending the first four years of college?: * Are you or your child attending the first four years of college? Yes No Tuition and fees paid: Student loan interest paid: Child care expenses: Are you eligible to participate in a work retirement plan?: * Are you eligible to participate in a work retirement plan? Yes No Retirement plan contributions:

SUCCESS !