Taxpayer and Dependent Information Please answer ALL questions as completely as possible so we can match you with as many Tax Credits as you are eligible for. Questions about the number of children or other dependants are very IMPORTANT because there are SEVERAL tax credits based upon the number of people YOU support. There are also tax credits specifically for college and continuing education for both you and any Dependants you support. (1) Your Name:_________________________ Date of Birth:____________________ Mailing address:__________________________________________ Full year resident of California?Yes/No_________________________ Your SSI # ______________ (2) Marital Status: Are You Married? Yes/No____________ Will you be filing jointly or separately? Yes/No_________________ (3) Your Spouse's name:______________________________________ Date of Birth:_______________________________ Mailing address:_______________________________________ Spouse's SSI #______________________________ Full Year Resident of California? Yes/No ____________________________________ Children and other Dependants: (4) First child's name:______________________ Date of birth:________________________ SSI number:___________________________ Did you provide over 50% of this Child's Support? Yes/No______________________ Approx number of Days last year child lived with you____________________ Can anyone else claim your child as a Dependant? Yes/No___________________ (5) Second child's name:__________________________ Date of birth:________________________ SSI number:___________________________ Did you provide over 50% of this Child's Support? Yes/No______________________ Approx number of Days last year child lived with you____________________ Can anyone else claim your child as a Dependant? Yes/No___________________ Third child's name:___________________________ Date of birth:________________________ SSI number:___________________________ Did you provide over 50% of this Child's Support? Yes/No______________________ Approx number of Days last year child lived with you____________________ Can anyone else claim your child as a Dependant? Yes/No___________________ If you have more Children please list Name, Date of Birth, SSI number below and Support questions for each Child: Child's name:___________________________ Date of birth:________________________ SSI number:___________________________ Did you provide over 50% of this Child's Support? Yes/No Approx number of Days last year child lived with you____________________ Can anyone else claim your child as a Dependant? Yes/No___________________ (6) Dependants you Support (You may be eligible for an additional tax credit for each additional Dependant over 18 you Support) Dependant's name:___________________________ Date of birth:________________________ SSI number:___________________________ Did you provide over 50% of Dependant's Support? Yes/No_______________________ Approx number of Days last year Dependant lived with you____________________ Can anyone else claim this person as a Dependant? Yes/No___________________ If you answer YES to any question below Please include copies of the relevant documents along with this questionaire: (7) All Income from jobs: Did you receive any forms W-2 for you or your spouse? Yes/No______________ (7a) All Self Employment or personal business income and expenses Yes/No_____________________ If Yes please list business name and business income and expenses (please use form 1040 Schedule C as a guide) __________________________________________ (7b) Social Security/Pension income or Unemployment (SSA 1099 statement, 1099 G) Yes/No____________________________ (8) Investment income or Mortgage expenses: forms 1099 for any interest paid or received, and stock dividends.Yes/No_____________________ (9) Income from state and local income tax overpayments/refunds? Yes/No________________________ (10) Taxable alimony received or paid (divorces finalized before January 1, 2019) Alimony received after this date is not Taxable.Yes/No_________________________________________ (11) If Yes, Date Divorce finalized_________________________________ (12) Income from sales of property? Escrow closing statement, cancelled debt information (Form 1099-C)Yes/No_________________ (13) All other income—jury duty, gambling winnings, Medical Savings Account (MSA), scholarships, etc.Yes/No____________________________ Adjustments to Your Income: (14) Do you use your home for business? Yes/No______________ If you answered Yes please list: Home size:____________________ Office size:_____________________ Home expenses (mortgage, rent, utilities, taxes:________________ Office expenses:________________________ (15) IRA contributions.Yes/No___________________________ (16) Student loan interest.Yes/No_______________________ (17) Health Savings Account (HSA) contributions.Yes/No___________________________ (18) Moving expenses (only moves INTO California are eligible) unless you are a member of the armed forces.Yes/No_______________________ (19) Self-employed health insurance premium payments.Yes/No______________________ (20) Self-employed pension plans.Yes/No___________________ (22) Educator expenses. Yes/No_____________________________ Tax Credits and Itemized Deductions (23) Childcare costs? Yes/No If Yes please list Childcare Provider’s name:_______________ Address:________________________ Tax id:____________________________ Amount Paid:______________ For more than one childcare provider please list the information above for each provider (24) Did you or your children pay for college last year? Yes/No_____________ If Yes Amounts spent on Tuition, Fees and School supplies___________________ If Yes, did you or your dependants receive a form 1098?Yes/No_____________________ (25) Did you pay Home mortgage interest, points and real estate taxes last year?Yes/No_________________ Did you receive a Form 1098? Yes/No__________________ (26) Did you make any Charitable donations last year?Yes/No_________________ If Yes, please list the value of each donation (Cash, Check or property) Date Donated and Recipient 1. 2. 3. (27) Did you experience any Casualty and theft losses last year? Yes/No_______________________ If Yes, please list amount of damage and any insurance reimbursements.__________________________ (28) Did you have out of pocket Medical and Dental expenses last year? Yes/No If Yes, please list what the expense was for, date paid, and amount:_______________________ (29) Did you purchase any Solar or energy conservation upgrades for your home? Yes/No_______________________________ If Yes, please item purchased, cost, and date installed:_________________________________ (30) Did you purchase a new or used electric or hybrid vehicle? Yes/No___________________________ If Yes, please list make, model and purchase price:_____________________________ --------------------------------------------------------------- By signing below, I certify the information I provided on and in connection with this form is true and correct to the best of my knowledge. I also understand that any false statements or deliberate omissions on this form may subject me to legal actions for fraudulent misrepresentation. Please type your full name(s) as husband/wife and date below: Name:_____________________________________________ Date:____________________________________________ Name:_____________________________________________ Date:_____________________________________________