Integrity Taxes 365

Customer Data Sheet

Customer Data Sheet

Integrity Taxes 365
For the year Jan. 1- Dec. 31, 20__ , or other tax year beginning
Name (As it appears on your Social Security Card) *

First Name Taxpayer Last Name
Soc. Sec. No. *
Name (If Married and Filing Jointly or Separately)

First Name Spouse Last Name
Soc. Sec. No.
I am interested in having the fee deducted from my refund *
Address *

Street Address

City

Is this City or County? State / Province

Postal / Zip Code
Tax Payer's Phone Number *
Please enter a valid phone number.
Tax Payer's Email *
example@example.com
Birthdate *

Month Day Year
Occupation *
Are You Married? *
Spouse Phone Number
Please enter a valid phone number.
Spouse Email
example@example.com
Spouse Birthdate

Month Day Year
Spouse Occupation

Dependents (list youngest first)

Name (First, Last)

Birthdate

Social Security Number

Months Lived With You?

Dependent

Childcare Provider's Name
SSN or EIN
Address

Provider's Address

Street Address Line 2

ZIP
Amount Paid
Check The Income Items Which Pertain To You *

State Tax Refund Wage Statement W-2's Unemployment Pension, Retirement Income Rental Income K-1 from any source 1099-Rs Social Security Benefits Lottery or Gambling Winnings Alimony Received Interest Income Dividends Self-Employed Business Income Tip Income Sale of home 1099-A/1099-C Did you sell any stock, real estate, business autos or business equipment? 1099-MISC. Dependents: (List youngest first) Name: (first name, last name) Phone: (Home) Married: Yes No Income from any state other than Maryland List states_____________ Other
To the best of my knowledge this information is correct and includes all income, deductions, and other information necessary for preparation of the year's income tax return. *

Clear
Below For Preparer Use Only: Preparer Number on Receipt

SSN & Name Verified
Preparer Number
SSN & Name Verified

All forms signed
ID

For Preparer Use Only: Preparer Number ol Receipt
ID#
Receipt #
ID

Accepted/Declined
Exp. Date

Month Day Year
Date
ID#
Issue Date

Month Day Year
Date
Exp. Date
Issue Date

Month Day Year
Date
Should be Empty:

Customer Data Form