Name (As it appears on your Social Security card):
 First:    Middle:   Last:

 Spouse Name (As it appears on your Social Security Card):
 First: Middle: Last:  

 Extension Code:
 
 
 Will we be completing your tax return?
  Yes - - - - - No
 
 Filing Status:
 Married Filing Joint
 Married Filing Separately
 Single
 Head of Household

 Dependent:
 Name: Date of Birth: Social Security #:
 Name: Date of Birth: Social Security #:
 Name: Date of Birth: Social Security #:

 U.S. Address:
 
 
 
 

 Foreign Address:
 
 
 
 

 Taxpayer Social Security Number:
 

 Spouse Social Security Number:
 

 W-2's
 Taxpayer or Spouse:
 
 Source:
 
 Taxable Income (Box 1 on form W-2):
 
 Federal Income Tax Withheld (Box 2 on form W-2):
 

 Taxpayer or Spouse:
 
 Source:
 
 Taxable Income (Box 1 on form W-2):
 
 Federal Income Tax Withheld (Box 2 on form W-2):
 

 Interest (Form 1099-INT)
 From: Amount:
 From: Amount:
 From: Amount:
 From: Amount:

 Dividends (Form 1099-DIV)
 From: Qualified: Ordinary:
 From: Qualified: Ordinary:
 From: Qualified: Ordinary:
 From: Qualified: Ordinary:

 Taxpayer IRA/Pension:
 Contributed: Received:

 Spouse IRA/Pension:
 Contributed: Received:

 Taxpayer Social Security Received (1099-SSA)
 Amount:
 Medicare Withheld:
 Tax Withheld:

Spouse Social Security Received (1099-SSA)
 Amount:
 Medicare Withheld:
 Tax Withheld:

 Capital Gains
 Stock Name:
             Date Sold:          Sale Price:
    Purchase Date: Purchase Cost:

 Stock Name:
             Date Sold:          Sale Price:
    Purchase Date: Purchase Cost:

 Stock Name:
             Date Sold:          Sale Price:
    Purchase Date: Purchase Cost:

 Stock Name:
             Date Sold:          Sale Price:
    Purchase Date: Purchase Cost:

Taxpayer Unemployment Compensation Received:
 Amount: Tax Withheld:

Spouse Unemployment Compensation Received
 Amount: Tax Withheld:

 Additional Income/Deductions:
 (Please explain, including source, amount, tax withheld, etc.)
 

 Disclaimer: Please make sure all information you have entered is accurate.  Any information here is
 considered correct per the client.  Information which is incorrectly entered may cause penalties or other
 liabilities to accrue.  Any penalties, interest, or any sort of liability which does occur due to incorrect or
 insufficient information entered by the client is not the fault of Expatriate Tax Online or Conlon &
 Company, CPA's, P.L.L.C., and as such we hold no responsibility on such occurrences.  In order to
 ensure information is correctly recorded on the final tax return, we REQUIRE all taxation/income
 documents be physically mailed to our address or e-mailed to us as a scanned PDF.