MEMBERSHIP FORM

Name

Suffix

Phone

Date

YYYY

Address

License ID

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SSN Card

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Have you filed your 2022 Tax return with us?

Yes

If not, please provide your 2022 AGI amount which is found on you2 1040 form Line 11

Are you claiming any dependents this year?

Dependent #1

Full name, Gender, Date of Birth and SSN, Relationship to the Taxpayer

Dependent #2

Full name, Gender, Date of Birth and SSN, Relationship to the Taxpayer

Dependent #3

Full name, Gender, Date of Birth and SSN, Relationship to the Taxpayer

Dependent #4

Full name, Gender, Date of Birth and SSN, Relationship to the Taxpayer

Did you receive any Child Tax Credit payments? (if applicable)

Did you pay any work-related child care expenses during 2023?

Tax Document 1

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Tax Document 2

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Tax Document 3

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Tax Document 4

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Tax Document 5

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Tax Document 6

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Tax Document 7

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Child Tax Credit (Letter 6419) attach if applicable

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Do you live at the same address as last year?

What is your Current Occupation?

Did you have health insurance from the Federal Health Insurance Marketplace (healthcare.gov) or a state-based exchange (Form 1095-A) attach if applicable.

Did you have any student loans or receive a Form 1098-E in 2023?

Did you make any charitable contributions for the year 2023?

Did you receive, sell, exchange, or otherwise dispose of any cryptocurrency during 2023?

Verification

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