Name *

First Name

Last Name

Phone *

(###)

###

####

Any Self-Employment Income? *

Yes

No

Do you itemize deductions?

Yes

No

Do you own your own home?

Yes

No

Did you receive $1,500 or more of interest income and/or dividends?

Yes

No

Did you sell any stocks and/or bonds?

Yes

No

Did you receive any rental income from real estate?

Yes

No

Did you have $10,000 or more in foreign bank accounts?

Yes

No