1. First Name*

2. Middle Name

3. Last Name

4. Date of Birth*

5. Social Security Number:

6. Are you using a Drivers License Or State ID?
YesNo

7. Number on your ID:

8. State Issued:

9. Issue Date:

10. Expiration Date:

11. Best contact number:*

12. Current Address:*

13. Best Email:*

14. Preferred language:*

15. Prefer to be contacted: via*
—Please choose an option—EmailPhoneText

16. Occupation:

17. Phone Carrier:

18. Did you have health insurance?
YesNo

19. If so What kind of healthcare you have?

20. Was it through your job, marketplace, government?

21. Were you in school?
YesNo

22. If so the name of the school?

23. Do you have the 1098T? please attach document (File Type Supports pdf, doc, docx, ppt)(File Size upto 5MB)

1. First Name

2. Middle Name

3. Last Name

4. Date of Birth

5. Social Security Number:

6. Are you using a Drivers License Or State ID?
YesNo

7. Number on your ID:

8. State Issued:

9. Issue Date:

10. Expiration Date:

11. Best contact number:

12. Current Address:

13. Best Email:

14. Preferred language:

15. Prefer to be contacted: via
EmailPhoneText

16. Occupation:

17. Phone Carrier:

18. Did you have health insurance?
YesNo

19. what kind of healthcare you have?

20. Was it through your job, marketplace, government?

21. Were you in school?
YesNo

22. If so the name of the school?

23. Do you have the 1098T? please attach document (File Type Supports pdf, doc, docx, ppt)(File Size upto 5MB)

1. Name:

2. Date Of Birth:

3. Social Security Number:

4. Your relationship to the dependent:

1. Name:

2. Date Of Birth:

3. Social Security Number:

4. Your relationship to the dependent:

1. Name:

2. Date Of Birth:

3. Social Security Number:

4. Your relationship to the dependent:

1. Have you worked last year?

2. Are you filing W-2s? If so How many?

3. Are you filing 1099s? If so How many?

4. What other documents are being filed?

5. Did you pay a mortgage?

6. If so do you have the interest form 1098?

1. If you have children did you pay for childcare?

2. If so how much?

3. Provide Daycare Name:

4. Provide Daycare EIN Number (Daycare should have this information):

5. Did you pay any tithes and offering to church?

6. How Much?

7. Did you give to charity?

8. How Much?

9. Did you have a business?

10. What kind of business did you have?

11. Please provide the EIN Number, Name of the business, and address of the business. (below)

12. Do you owe any student loans, parking tickets, child support etc.?

13. If yes who do you owe and how much do you owe?

14. Any additional paperwork you have as relating to expenses as well.

15. Are you interested in the cash advance up to $6000?

16. If interested in cash advance would you like to receive your funds via
—Please choose an option—Walmart Money CardCheck

17. If you are not interested in the cash advance how would you like to receive your return?
—Please choose an option—CheckDirect DepositGreen Dot Card

18. If you would like to receive direct deposit Please provide the Bank name routing and account number? (Attach bank info in tax pass or in this email)

19. Did you receive a stimulus last year? If yes please provide amount:

20. Did you receive stimulus for this year?

21. If yes how much?