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First Name:
Middle Initial
Last Name
Email:
Current Address:
City:
State:
Zip Code:
Phone:
Work Phone:
Cell:
Age:
Marital Status:
If you answered "Married" above fill in the information about your spouse below
Spouse's First Name
Spouse's Middle Initial
Spouse's Last Name
Spouse's Age:
Occupation:
Spouse's Occupation:
Do you own or rent?
Do you have any children that you care for that live in your home?
If "Yes" how many?
If you answered "Yes" above, what is their relationship to you?
Do you have any other persons that you care for and pay over 50% of the bills and up-keep for?
If "Yes" how many?
If you answered "Yes" above, what is their relationship to you?
What is your total annual salary? If married filing jointly, include both salaries. Salary may include W-2 income, any 1099 income, Unemployment Compensation income, Self-Employment income, etc.
Do you pay for daycare? If yes, give an estimate of how much in 2004?
Did you receive Unemployment Compensation in 2004?
Did you pay tuition for college/university or a higher education institution during 2004?
Thank you for completing the Tax Assessment form! A Smart-Choice Tax Service Specialist will contact you within shortly to give you your results and allow you to receive a FREE Telephone Tax Consultation if needed on any questions or concerns that you may have.
Please tell us anything else you think would be helpful for us to know:
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