01/22/2024
PLEASE enclose this in our envelope with your information.
Name _________________________________ Social Security # ________________
Name _________________________________ Social Security # ________________
Address ____________________________________________________________
Township _______________________ If you moved, when? _________________
Phone _______________________ Phone ____________________
Filing Status on December 31, 2023 Please circle
Single Married Married Filing Separate Head of Household Dependent of Another
Names of Dependents __________________________________________________
Provide proof of dependents! Their name, your address and the year 2023. School record, medical bill, etc.
Child care expense? Daycare name, address and social security number or EIN
New born dependent? We need a copy of birth certificate and Social Security card.
Work related expenses? ____________Union Dues __________Uniforms_________
If you renewed driver’s license in 2023,
Renewal date __________________ Expiration date ____________________
Bank Name _________ Routing # __________ Account # _____________Checking or Savings
Unemployment 1099-G downloadable from web site
Healthcare through the Pennie Marketplace? Provide your Form 1095-A
Health Savings Account (HSA) Form 1099-SA, even if you took no money out.
Gambling winnings _______________ Gambling losses _______________
Energy Credit – Energystar.gov (windows, heat system, etc) Provide receipt
Education Credit Form 1098-T from college Student loan interest Form 1098-E
Paid Property tax bills if you are over 65 and applying for Property Tax Rebate.
New clients – copy of driver’s license, social security cards, date of births, prior year tax return