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Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Did you have marketplace insurance (Obama Care) in 2024?

Yes

Date of Birth

YYYY

Social Security #

Driver License #

State Issued

Issue Date

YYYY

Expiration Date

YYYY

Banking Institution

Routing #

Account #

Are you currently employed?

Are you self employed?

Occupation

Name of Employer

Employer Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Did you pay for childcare or dependent care?

Yes

Employer EIN

Dependent Name

First Name

Last Name

Social Security #

Date of Birth

YYYY

Gender

Dependent Name

First Name

Last Name

Social Security #

Date of Birth

YYYY

Gender

Dependent Name

First Name

Last Name

Social Security #

Date of Birth

YYYY

Gender

BY SUBMITTING THIS FORM, YOU GIVE A&M TAX AND ACCOUNTING SERVICES, LLC YOUR PERMISSION TO HANDLE ALL OF YOUR TAX AND ACCOUNTING NEEDS AND AFFIRM THAT ALL INFORMATION PROVIDED IS CORRECT AND TRUE TO THE BEST OF YOUR KNOWLEDGE.

Let’s work together.

BY SUBMITTING THIS FORM, YOU GIVE A&M TAX AND ACCOUNTING SERVICES, LLC YOUR PERMISSION TO HANDLE ALL OF YOUR TAX AND ACCOUNTING NEEDS AND AFFIRM THAT ALL INFORMATION PROVIDED IS CORRECT AND TRUE TO THE BEST OF YOUR KNOWLEDGE.

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