Integrity Tax Services

Tax Service Request Form

Applicant Information
First Name: *
Last Name: *
Taxpayer’s SSN: *
Date of Birthday: *
Address Street 1: *
Address Street 2:
City: *
Zip Code: *	(5 digits)
State:

W2 or 1099’s
Employer's Federal ID#:
Company Name:
Company Address:
Box #1 (Total Wages):
Box #2 (Federal tax withheld):

Spouse Information
First Name:
Last Name:
Taxpayer’s SSN:
Date of Birth:

W2 or 1099’s
Employer's Federal ID#:
Company Name:
Company Address:
Box #1 (Total Wages):
Box #2 (Federal tax withheld):

Contact Information
Daytime Phone: *
Evening Phone:
Email: *
Filing Information
Filing Status::	Single Married Filing Separate Married Filing Jointly Head of Household
Dependent Information
Name:
SSN:
Date of Birth:
Relationship:

Name:
SSN::
Date of Birth:
Relationship:

Name:
SSN:
Date of Birth:
Relationship:

Other Information
Comments:
	I declare under penalty of perjury that the information on this form is accurate, true and complete to the best of my knowledge and that Integrity Tax Services is not liable for any false information produced on this form. I Agree