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Full Name
Mobile Phone
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Zip Code
Your Age
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18 - 24
25 - 64
Over 65
YTD Gross Income?
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$3,000 - $9,999
$10,000 - $19,999
$20,000 - $34,999
greater than $35,000
FED withholding
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$0 - $499
> $500
> $1000
greater than > $1500
How many dependents are 18 and under?
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0
1 to 2
3 or more
Where did you file your taxes last year?
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ATC
Other
Did you receive a refund last year?
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YES
NO – AUDITED
I HAD FED BALANCE DUE
Do you any of the following debts/offsets?
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IRS OR STATE
CHILD SUPPORT
STUDENT LOANS
NONE
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