Personal Information

Full Name *

Phone *

Email *

Date Of Birth

Address

Street Address

City

State

Country

Postal Code

Occupation

Are you a full-time student?

Yes

No

Are you totally and permanently disabled?

Yes

No

Are you legally blind?

Yes

No

Spousal Information

Spouse Full Name

Spouse Date Of Birth

Spouse Email

Spouse Address

Street
City
State
Zip Code

Are they a full-time student?

Yes

No

Are they totally and permanently disabled?

Yes

No

Are they legally blind?

Yes

No

Are they your dependent?

Yes

No

Dependents

Enter your dependents here

Name
Name
Name
Name
Name

Tax Questions

Are you contributing to 401k or other pre-tax account?

Yes

No

Is this your first time opening a pre-tax account?

Yes

No

Are you currently renting?

Yes

No

What is the monthly rental amount?

General Expenses

Enter the following expenses total amount

Medical Expenses
Dental Expenses
Insurance Premiums paid
Insurance Premiums paid
Prescription Drugs and Medications
Home Mortgage
Investment Interest
Cash Contributions
Non-Cash Contributions
Unreimbursed Business Expenses
Union Dues
Tax Preparation Fees
Investment Expenses

Other Expenses (Describe)

Total Expenses

ACKNOWLEDGMENT & SIGNATURE

I confirmed that all information I entered here is accurate and true.
I allow Protected with Love to capture my sensitive data like personal id, government id, social security number (SSN), and other information.
I have read the terms and conditions and privacy policy of Protected with Love.
By signing below, you acknowledge that you have read and understood your responsibilities and our responsibilities in doing this tax return.

I confirm that the information provided above is accurate to the best of my knowledge and reflects expenses incurred for business purposes. My signature certifies I understand this.

Signature *

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