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Step 1 of 4
25%
Part I – Your Personal Information (If you are filing a joint return, enter your names in the same order as last year’s return)
1. Your
First name
M.l
Last name
Telephone Number
Are you a U.S. citizen?
Yes
No
2. Your spouse’s
First name
M.l
Last name
Telephone Number
Is your spouse a U.S. citizen?
Yes
No
3. Mailing address
Street Address
Apt#
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
4. Your Date of Birth
5. Your job title
6. Last year, were you:
a. Full-time student
Yes
No
b. Totally and permanently disabled
Yes
No
c. Legally blind
Yes
No
7. Your spouse’s Date of Birth
8. Your spouse’s job title
9. Last year, was your spouse:
a. Full-time student
Yes
No
b. Totally and permanently disabled
Yes
No
c. Legally blind
Yes
No
10. Can anyone claim you or your spouse as a dependent?
Yes
No
Unsure
11. Have you or your spouse:
a. Been a victim of identity theft?
Yes
No
b. Adopted a child?
Yes
No
Part II – Marital Status and Household Information
1. As of December 31, 2017, were you
Never Married
Married
Divorced
Legally Separated
Widowed
(This includes registered domestic partnerships, civil unions, or other formal relationships under state law)
a. If Yes, Did you get married in 2017?
Yes
No
b. Did you live with your spouse during any part of the last six months of 2017?
Yes
No
Date of final decree
Date of separate maintenance agreement
Year of spouse’s death
2. List the names below of:
everyone who lived with you last year (other than your spouse)
anyone you supported but did not live with you last year
Name (first, last) Do not enter your name or spouse’s name below (a)
Date of Birth (b)
Relationship to you (for example: son, daughter, parent, none, etc) (c)
Number of months lived in your home last year (d)
US Citizen (e)
Resident of US, Canada, or Mexico last year (f)
Single or Married as of 12/31/17 (g)
Full-time Student last year (h)
Totally and Permanently Disabled (i)
Yes
No
Yes
No
S
M
Yes
No
Yes
No
Part III – Income – Last Year, Did You (or Your Spouse) Receive
Check appropriate box for each question in each section
1. (B) Wages or Salary? (Form W-2)
Yes
No
Unsure
If yes, how many jobs did you have last year?
2. (A) Tip Income?
Yes
No
Unsure
3. (B) Scholarships? (Forms W-2, 1098-T)
Yes
No
Unsure
4. (B) Interest/Dividends from: checking/savings accounts, bonds, CDs, brokerage? (Forms 1099-INT, 1099-DIV)
Yes
No
Unsure
5. (B) Refund of state/local income taxes? (Form 1099-G)
Yes
No
Unsure
6. (B) Alimony income or separate maintenance payments?
Yes
No
Unsure
7. (A) Self-Employment income? (Form 1099-MISC, cash)
Yes
No
Unsure
8. (A) Cash/check payments for any work performed not reported on Forms W-2 or 1099?
Yes
No
Unsure
9. (A) Income (or loss) from the sale of Stocks, Bonds or Real Estate? (including your home) (Forms 1099-S,1099-B)
Yes
No
Unsure
10. (B) Disability income? (such as payments from insurance, or workers compensation) (Forms 1099-R, W-2)
Yes
No
Unsure
11. (A) Payments from Pensions, Annuities, and/or IRA? (Form 1099-R)
Yes
No
Unsure
12. (B) Unemployment Compensation? (Form 1099G)
Yes
No
Unsure
13. (B) Social Security or Railroad Retirement Benefits? (Forms SSA-1099, RRB-1099)
Yes
No
Unsure
14. (M) Income (or loss) from Rental Property?
Yes
No
Unsure
15. (B) Other income? (gambling, lottery, prizes, awards, jury duty, Sch K-1, royalties, foreign income, etc.)
Yes
No
Unsure
Specify
Part IV – Expenses – Last Year, Did You (or Your Spouse) Pay
1. (B) Alimony or separate maintenance payments?
Yes
No
Unsure
If yes, do you have the recipient’s SSN?
Yes
No
2. Contributions to a retirement account?
Yes
No
Unsure
IRA (A)
401K (B)
Roth IRA (B)
Other
3. (B) College or post secondary educational expenses for yourself, spouse or dependents? (Form 1098-T)
Yes
No
Unsure
4. (B) Unreimbursed employee business expenses? (such as uniforms or mileage)
Yes
No
Unsure
5. (B) Medical expenses? (including health insurance premiums)
Yes
No
Unsure
6. (B) Home mortgage interest? (Form 1098)
Yes
No
Unsure
7. (B) Real estate taxes for your home or personal property taxes for your vehicle? (Form 1098)
Yes
No
Unsure
8. (B) Charitable contributions?
Yes
No
Unsure
9. (B) Child or dependent care expenses such as daycare?
Yes
No
Unsure
10. (B) For supplies used as an eligible educator such as a teacher, teacher’s aide, counselor, etc.?
Yes
No
Unsure
11. (A) Expenses related to self-employment income or any other income you received?
Yes
No
Unsure
12. (B) Student loan interest? (Form 1098-E)
Yes
No
Unsure
Part V – Life Events – Last Year, Did You (or Your Spouse)
1. (HSA) Have a Health Savings Account? (Forms 5498-SA, 1099-SA, W-2 with code W in box 12)
Yes
No
Unsure
2. (A) Have debt from a mortgage or credit card cancelled/forgiven by a commercial lender? (Forms 1099-C, 1099-A)
Yes
No
Unsure
3. (A) Buy, sell or have a foreclosure of your home? (Form 1099-A)
Yes
No
Unsure
4. (B) Have Earned Income Credit (EIC) or other credits disallowed in a prior year?
Yes
No
Unsure
If yes, for which tax year?
5. (A) Purchase and install energy-efficient home items? (such as windows, furnace, insulation, etc.)
Yes
No
Unsure
6. (B) Live in an area that was affected by a natural disaster?
Yes
No
Unsure
If yes, where?
7. (A) Receive the First Time Homebuyers Credit in 2008?
Yes
No
Unsure
8. (B) Make estimated tax payments or apply last year’s refund to this year’s tax?
Yes
No
Unsure
If so how much?
8. (B) Make estimated tax payments or apply last year’s refund to this year’s tax?
Yes
No
Unsure
9. (A) File a federal return last year containing a “capital loss carryover” on Form 1040 Schedule D?
Yes
No
Unsure
Part VI - Health Care Coverage - Last year, did you, your spouse, or dependent(s)
Check appropriate box for each question in each section
1. (B) Have health care coverage?
Yes
No
Unsure
2. (B) Receive one or more of these forms?
Yes
No
Unsure
(Check the box)
Form 1095-B
Form 1095-C
3. (A) Have coverage through the Marketplace (Exchange)? [Provide Form 1095-A]
Yes
No
Unsure
3a. (A) If yes, were advance credit payments made to help you pay your health care premiums?
Yes
No
Unsure
3b. (A) If yes, Is everyone listed on your Form 1095-A being claimed on this tax return?
Yes
No
Unsure
4. (B) Have an exemption granted by the Marketplace?
Yes
No
Unsure
Visit
http://www.healthcare.gov/
or call 1-800-318-2596 for more information on health insurance options and assistance.
If advance payments of the premium tax credit were paid on your behalf to help pay your health insurance premiums, you should report life changes, such as, income, marital status or family size changes, to your Marketplace. Reporting changes will help to make sure you are getting the proper amount of advance payments.
Part VII – Additional Information and Questions Related to the Preparation of Your Return
1. Provide an email address (optional) (this email address will not be used for contacts from the Internal Revenue Service)
3. If you are due a refund, would you like:
a. Direct deposit
Yes
No
b. To split your refund between different accounts
Yes
No
4. If you have a balance due, would you like to make a payment directly from your bank account?
Yes
No
Direct Deposit Information
Banks Name
Routing Number
Account Number
Additional comments
Privacy Act and Paperwork Reduction Act Notice
The Privacy Act of 1974 requires that when we ask for information we tell you our legal right to ask for the information, why we are asking for it, and how it will be used. We must also tell you what could happen if we do not receive it, and whether your response is voluntary, required to obtain a benefit, or mandatory.
Our legal right to ask for information is 5 U.S.C. 301. We are asking for this information to assist us in contacting you relative to your interest and/or participation in the IRS volunteer income tax preparation and outreach programs. The information you provide may be furnished to others who coordinate activities and staffing at volunteer return preparation sites or outreach activities. The information may also be used to establish effective controls, send correspondence and recognize volunteers. Your response is voluntary. However, if you do not provide the requested information, the IRS may not be able to use your assistance in these programs.
The Paperwork Reduction Act requires that the IRS display an OMB control number on all public information requests. The OMB Control Number for this study is 1545-1964. Also, if you have any comments regarding the time estimates associated with this study or suggestion on making this process simpler, please write to the Internal Revenue Service, Tax Products Coordinating Committee, SE:W:CAR:MP:T:T:SP, 1111 Constitution Ave. NW, Washington, DC 20224
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