Part 1 - Your information

Please Check Your Answers To Yes/No Questions

Did you file your tax return last year?
Yes
No

Did Tax-Aid prepare your tax return last year?
Yes
No

Have you already filed a tax return this year?
Yes
No

Have you or your spouse received any letters from the IRS?
Yes
No

Taxpayer's name
First Middle Last

Spouse's name First Middle Last

Personal Information	Taxpayer	Spouse
Social Security Information
If you have an Individual Taxpayer Identification Number(ITIN), please fill it in
Mobile Phone Number
Birth Date (Month/Day/Year)
Are you a U.S. citizen? (Check the box if naturalized)	Yes No	Yes No
Are you a full-time student?	Yes No	Yes No
Are you claimed as a dependent on another person’s tax return such as your parent?	Yes No	Yes No
Are you legally blind?	Yes No	Yes No
Last year were you permanently disabled?	Yes No	Yes No
Home Phone
Email Address (PLEASE PRINT CLEARLY)
Home Address
City
State
Zip Code
Apt./Unit

Employment Information	Taxpayer	Spouse
What is your job / job title?
Employer name(s)
How long have you worked there?
How are you paid (monthly, weekly, cash)?

Part 2 - How Are You Filing?

Single (including registered domestic partnerships, civil unions, or other formal relationships under state law)

Married filing separately - Date of final decree or separate maintenance agreement - Spouse's name: First Middle Last - Spouse: Social Security Number or ITIN:

Married filing jointly - Was your marriage recognized under state law for the state(s) you are filing in? Yes No
- Were you married as of December 31 of last year?
Yes No

Head of Household
- Did your spouse live with you during any part of the last six months of the tax year? Yes No

Qualifying Surviving Spouse - Year of spouse's death - Do you have a dependent child or stepchild that you claim on your tax return? Yes No

If you/your spouse were a victim(s) of identity theft and received an e-filing IP PIN from the IRS, what is the IP PIN?

E-Filing IP PIN	You	Your spouse
IP PIN #
Type of ID
ID #
State ID issued
Issue date
Expiration date

The fastest way to get your tax refund is via direct deposit to your bank account. If you want Direct Deposit for your tax refund, list your banking information.

Bank name
Routing number
Account number
Type of Account	Checking Savings

Part 3 Dependents - If no dependents, skip to Part 4

Have you or your spouse adopted a child?
Yes
No

Scroll sideways to view all table columns

US Citizen	Resident of US, Canada or Mexico last year	Full-time Student?	Totally and Permanently Disabled?
Yes No	Yes No	Yes No	Yes No
Yes No	Yes No	Yes No	Yes No
Yes No	Yes No	Yes No	Yes No
Yes No	Yes No	Yes No	Yes No
Yes No	Yes No	Yes No	Yes No

Part 4 - Last year, did you, your spouse, or all your dependents...

1. Did you, your spouse, and all of your dependents have health insurance for the entire tax year?
Yes
No

2. Receive one or more of these forms?
Yes
(Check the box) 1095-B 1095-C No

3. Have coverage through the Marketplace (Exchange)?
Yes
(Check the box) 1095-A California Form 3895 a. If yes, receive an advanced payment from the Marketplace to help pay your monthly health care payments? Yes No b. If yes, is everyone listed on your Form 1095-A being claimed on this tax return? Yes No No

4. Have an exemption granted by the Marketplace?
Yes
Reason
No

Part 4A - Did You or Your Spouse Receive...?

1. Wages (W-2)
Yes
a. I received 1-5, 6 or more W-2S? Circle the amount(s) that apply to you 1-5 6+ No

2. Did you work for In Home Support Services (IHSS)?
Yes
No

2a. If you answered yes to question 2, do you live in the same residence with the person you provide In Home Support Services to?
Yes
No

3. Tips
Yes
No

4. Scholarships (1098-T)
Yes
No

5. Interest/dividends (1099-INT, 1099-DIV)
Yes
No

6. State/local tax refund (1099-G)
Yes
No

7. Alimony income or separate maintenance payments
Yes
Date of decree
No

8. Self-employment income (1099-MISC, 1099-NEC, Cash)
Yes
No

9. Income for work not reported on Forms W-2/1099
Yes
No

10. Did you receive 1099-K? Yes - in exchange for performing any services and goods? Yes No No 10a. Why did you receive 1099-K?

11. Did you earn income outside California?
Yes
No

12. Transactions of stocks/bonds/real estate (1099-S, 1099-B)
Yes
No

13. Disability income (insurance/workers comp) (Forms 1099-R, W-2)
Yes
No

14. Pension, annuity, IRA distributions (IRS)(1099-R)
Yes
No

15. Did you withdraw from your IRA or other retirement accounts?
Yes
No 15a. If you answered Yes to question 15, please select the reason for withdrawal COVID-19 Normal Distribution (RMD) Rollover Other:

16. Unemployment compensation (Form 1099-G)
Yes
No

17. Social Security, Railroad Retirement Board (SSA-1099, RRB-1099)
Yes
No

18. Income (or loss) from rental property
Yes
No

19. Other income (gambling/lottery W2-G, prizes/awards, jury duty, Schedule K-1, etc.)
Yes
No

20. Have you purchased and/or sold any cryptocurrency (example bitcoin)?
Yes (Check the box)

Purchased cryptocurrency or any other digital assets (example Non Fungible Token) Sold cryptocurrency

21. Have you received or paid any cryptocurrency (example bitcoin) in exchange for performing any services?
Yes
No

22. Are you between the ages of 18-24 years old?
Yes
No

23. Were you a part of the Foster Youth Program?
Yes
No

Part 4B - Did You or Your Spouse Pay...

1. Rent (you could qualify for the California Renter's Credit)
Yes
No

2. Was your home rental considered subsidized housing?
Yes
No

3. Alimony or separate maintenance payments
Yes
Date of decree
No

4. Contributions to a retirement account
Yes
No

5. Post secondary education expenses (1098-T)
Yes
No

6. Medical expenses
Yes
No

7. Home mortgage interest (1098)
Yes
No

8. Student loan interest (Form 1098-E)
Yes
No

9. Real estate taxes or personal property taxes (1098)
Yes
No

10. Charitable contributions Yes a. Amount of contributions $ b. How was this contribution made (Check the box) Cash Check Credit Card No

11. Child or dependent care expenses such as daycare
Yes
No

12. For supplies as an educator (i.e., teacher, teacher's aide, counselor, etc.) (Form 1098-E)
Yes
No

13. Expenses related to self-employment income or any other income you received.
Please complete the attached sheet: https://tinyurl.com/2p8x4ub9
Yes
a. I had 1-5, 6-9, 10 or more expenses? Circle the amount(s) that apply to you

1-5 6-9 10+

Part 4C - Did you have...

1. Health Savings Account (5498-SA, 1099-SA, W2 with Code W in box 12)
Yes
No

2. Have debt cancelled/forgiven/Credit card/mortgage (1099-C, 1099-A)
Yes
No

3. Buy, sell, foreclose (COD) your home (Form 1099-A)
Yes
No

4. Has Earned Income Credit (EIC) or Child Tax Credit (CTC) disallowed a prior year?
Yes
Which year?
No

5. Purchase/install energy-efficient home items (such as windows, etc.)
Yes
How much did you pay?
No

6. Live in an area that was affected by a natural disaster
Yes
If yes where?
No

7. Estimated tax payments for 2023
How much did you pay 4/15? $ How much did you pay 6/15? $ How much did you pay 9/15? $ How much did you pay 1/15? $

8. A "capital loss carryover" (on Form 1040 Schedule D)
Yes
No

9. Receive the First Time Homebuyers Credit in 2008 (interest free $7500 loan)
Yes
No

Tax–Aid depends on grants and contributions to operate our free tax sites. The data from the following optional questions may be used to apply for these grants and for statistical purposes.

1. Ethnicity: check all that apply

2. What is your gender? (Check one that that best describes your current gender identity)

Female
Male
Gender Queer
Gender Non-binary
Transgender Female
Transgender Male
Transgender
Prefer not to answer
Other

3. Do you or any member of your household have a disability?
Yes
No

Prefer not to answer

4. Are you or your spouse a Veteran from the U.S. Armed Forces?
Yes
No

Prefer not to answer

5. How did you hear about us?

Tax-Aid did my return before
Internet search
Another nonprofit
Family or friend
Instagram
Facebook
Other (please write in)

Taxpayer Agreement to Disclose

We will not share or use personal identifying information including your social security number, ITIN, date of birth, refunds or personal financial information. We will only use your contact information to inform you of other services that may benefit you. We will use and keep your data combined with THOUSANDS of other taxpayers for the duration of the free tax preparation program to share results like this

Tax-Aid 2023 Results
3,181 tax returns
$1,615,106 million in total refunds

The following persons, groups or organizations receive the combined data results:

Free tax preparation program donors and volunteers
Various media partners
Elected officials and other program supporters
General public

Consent to Disclose

Federal law requires this consent form be provided to you. Unless authorized by law, we cannot disclose, without your consent, your tax return information to third parties for purposes other than the preparation and filing of your tax return. If you consent to the disclosure of your tax return information, Federal law may not protect your tax return information from further use or distribution. You are not required to complete this form. If we obtain your signature on this form by conditioning our services on your consent, your consent will not be valid. If you agree to the disclosure of your tax return information, your consent is valid for the amount of time that you specify. If you do not specify the duration of your consent, your consent is valid for one year. If you believe your tax return information has been disclosed or used improperly in a manner unauthorized by law or without your permission, you may contact the Treasury Inspector General for Tax Administration (TIGTA) by telephone at 1-800-366-4484, or by email at complaints@tigta.treas.gov. Yes, I agree to share my tax return information with the above persons, groups or organizations

No, I do not agree to share my tax return information with the above persons, groups or organizations

Name(s)		Date
Signature		Spouse's Signature

TAX-AID CLIENT PRIVACY NOTICE

FACTS	WHAT DOES TAX-AID DO WITH YOUR PERSONAL INFORMATION?
WHY?	U.S. federal law provides clients with the right to limit some but not all of a company’s decisions with respect to the sharing of the client’s personal information. U.S. federal law also requires us to tell you how we collect, share and protect your personal information. Please read this notice carefully to understand what we do.
WHAT?	We collect nonpublic personal information about you that is either provided by you or obtained by us with your authorization. The types of personal information we collect and share depend on the particular service that we provide to you. This information can include your: name; Social Security number; Individual Taxpayer Identification Number; address; date of birth; bank account information; employment details; earnings and expenses; family members’ names, dates of birth, Social Security numbers and earnings (if any); contact information (phone number and email address);
HOW?	Accounting service companies need to share their clients’ personal information to run their everyday business. In the section below, we list the reasons accounting service companies can share their clients’ personal information, the reasons Tax-Aid chooses to share some of this information and whether you can limit this sharing. Once you are no longer our client, we can continue to share your information as described in this notice.

Reasons we can share your personal information	Does Tax-Aid share?	Can you limit this sharing?
For our everyday business purposes - such as to process your tax filings, maintain your account(s), respond to court orders and legal investigations, or report to credit bureaus	Yes	No
For our marketing purposes - to offer our services to you	No	We don’t share
For joint marketing with other companies	No	We don’t share
For Nonaffiliates (defined below) to market to you	No	We don’t share

QUESTIONS?

Call us at 415-229-9240 or email us at admin@tax-aid.org

Who we are
Who is providing this notice?	Tax-Aid
What we do
How does Tax-Aid protect my personal information?	To protect your personal information from unauthorized access and use, we use security measures that comply with federal law. These measures include physical, electronic and procedural safeguards.
How does Tax-Aid collect my personal information?	We collect your personal information, for example, when you submit your tax documents to us; contact us with questions; and work with one of our tax professionals to prepare your taxes.
Why can’t I limit all sharing?	U.S. federal law gives you the right to limit only our sharing to Nonaffiliates to market to you. State laws and individual companies may give you additional rights to limit sharing.

Definitions
Nonaffiliates	Companies not related by common ownership or control. Such companies can be financial and nonfinancial companies.
Joint marketing	A formal agreement between nonaffiliated companies that together market products or services to you. Tax-Aid does not jointly market.

Other important information

N/A

Tax-Aid Questionnaire