Republic Tax

CASEID - Do not edit

FIRST NAME*

LAST NAME*

Social Security Number*

Occupation*

Work Phone

Cell Phone

Email

Driver's License/ID issuing state*

License/ID Number*

License/ID Issue Date

License/ID Expiration Date

Birthdate*

Were you or your spouse blind, permanently and totally disabled this year?*

Yes
No

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Tax Year Being Prepared*

Filing Status*

Spouse FIRST NAME*

Spouse LAST NAME*

Spouse Social Security Number*

Spouse Birthdate*

Spouse Driver's License/ID issuing state*

Spouse License/ID Number*

Spouse License/ID Issue Date*

Spouse License/ID Expiration Date*

Spouse Occupation*

Which year did your spouse passed away?*

If the qualifying person is a child but not your dependent, enter child's name*

If the qualifying person is a child but not your dependent, enter child's social security number*

Do you have any of W2 or 1099 income or Profit and loss statements?

YES
NO

Upload your W2 and/or 1099 and/or Profit and loss statements HERE

Drop files here or

Copy of each taxpayer's State Issued ID or Driver's License*

Drop files here or

Copy of your form 1095 A,B or C - Healthcare Coverage Statement

Yes
No

Copy of your form 1095 A,B or C - Healthcare Coverage Statement

Drop files here or

Copy of Form 1098 - Mortgage and other interest paid and 1099-INT interest received

Yes
No

Copy of Form 1098 - Mortgage and other interest paid and 1099-INT interest received

Drop files here or

Copy of property tax bill

Yes
No

Copy of property tax bill

Drop files here or

Copy of vehicle license fee paid

Yes
No

Copy of vehicle license fee paid

Drop files here or

Copy of your previous year tax return (if we don't have it already)

Yes
No
You have a copy already.

Copy of your previous year tax return (if we don't have it already)

Drop files here or

Copy of brokerage statements of stocks/bonds

Yes
No

Copy of brokerage statements of stocks/bonds

Drop files here or

At any time during the year did you receive, sell, exchange, or otherwise dispose of any financial interest in any virtual currency?

Yes
No

Attach the forms

Drop files here or

Copy of 1098T - School tuition payment

Yes
No

Copy of 1098T - School tuition payment for tax payers and/or dependents

Drop files here or

Did you make any charity donations in the tax year we are preparing for you?

Yes
No

Please provide receipt or evidence of donation.

Drop files here or

Dependent Information

For the dependent code, please use the following:
L = Dependent child who lived with you
N = Dependent child who didn't live with you due to divorce or separation
O = Other dependent
Q = not a dependent but is a person who qualifies your client for the earned income credit and/or the credit for child and dependent care expenses.

Dependent One

Dependent's code. Please use above info for reference

Dependent's Full Name

Dependent's Social Security Number

Dependent's relationship to tax payer

Dependent's Date of Birth

Check this box if dependent child is not a US citizen or resident alien

Enter the number of months dependent lived with you and/or your spouse if married filing jointly in the US in the tax year we are preparing for you.

How much is dependent's child care expense? -1

Please provide receipt or evidence of dependent expenses.

Drop files here or

Dependent Two

Dependent's code. Please use above info for reference

Dependent's Full Name

Dependent's Social Security Number

Dependent's relationship to tax payer

Dependent's Date of Birth

Check this box if dependent child is not a US citizen or resident alien - 2

Enter the number of months dependent lived with you and/or your spouse if married filing jointly in the US.

How much is dependent's child care expense? -2

Please provide receipt or evidence of dependent expenses.

Drop files here or

Dependent Three

Dependent's code. Please use above info for reference

Dependent's Full Name

Dependent's Social Security Number

Dependent's relationship to tax payer

Dependent's Date of Birth

Check this box if dependent child is not a US citizen or resident alien - 3

Enter the number of months dependent lived with you and/or your spouse if married filing jointly in the US.

How much is dependent's child care expense? -3

Please provide receipt or evidence of dependent expenses.

Drop files here or

Dependent Four

Dependent's code. Please use above info for reference

Dependent's Full Name

Dependent's Social Security Number

Dependent's relationship to tax payer

Dependent's Date of Birth

Check this box if dependent child is not a US citizen or resident alien -4

Enter the number of months dependent lived with you and/or your spouse if married filing jointly in the US.

How much is dependent's child care expense? -4

Please provide receipt or evidence of dependent expenses.

Drop files here or

Dependent Five

Dependent's code. Please use above info for reference

Dependent's Full Name

Dependent's Social Security Number

Dependent's relationship to tax payer

Dependent's Date of Birth

Check this box if dependent child is not a US citizen or resident alien -5

Enter the number of months dependent lived with you and/or your spouse if married filing jointly in the US.

How much is dependent's child care expense? -5

Please provide receipt or evidence of dependent expenses.

Drop files here or

Questions Section

Did a lender cancel any of your debt this year?

Yes
No

Upload your form 1099 A or C

Do you have any dependent who must file taxes?

Yes
No

What is the name of that dependent?*

Did you receive a total distribution from an IRA or other qualified plan that was partially or totally rolled over into another IRA or qualified plan within 60 days of the distribution?

Yes
No

Did you receive any disability payments this year?

Yes
No

Did you buy/sell refinance foreclose or abandon principal residence or other real property this year?

Yes
No

Attach closing or escrow statements and/or 1099 C and/or 1099 A form

Drop files here or

If you paid any alimony, enter recipient's SSN:

If you paid any alimony, enter recipient's name

If you paid any alimony, enter recipient's amount paid

Did you receive any income not included in this tax organizer?

Yes
No

Please provide documents of income.

Drop files here or

Did you receive a stimulus check in 2020 &/or 2021? If you have missing stimulus check, please let us know.

Yes
No

Any Questions/Notes/Concerns? Write it here

Republic Tax - TAX PREP SURVEY

Dependent Information

Dependent One

Dependent Two

Dependent Three

Dependent Four

Dependent Five

Questions Section