Carter Capital PLLC
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Taxpayer
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AL - Alabama
AK - Alaska
AZ - Arizona
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CA - California
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CT - Connecticut
DE - Delaware
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FL - Florida
GA - Georgia
HI - Hawaii
ID - Idaho
IL - Illinois
IN - Indiana
IA - Iowa
KS - Kansas
KY - Kentucky
LA - Louisiana
ME - Maine
MD - Maryland
MA - Massachusetts
MI - Michigan
MN - Minnesota
MS - Mississippi
MO - Missouri
MT - Montana
NE - Nebraska
NV - Nevada
NH - New Hampshire
NJ - New Jersey
NM - New Mexico
NY - New York
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ND - North Dakota
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PA - Pennsylvania
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ID Issue Date
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Occupation
Dependents
Dependent
1
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Middle Name
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Type of Relationship
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Son
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Dependent
2
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Son
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Dependent
3
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Son
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Dependent
4
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Son
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Dependent
5
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Son
Daughter
Step Child
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Other
Is Dependent a Student?
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Is Dependent Disabled?
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Dependent
6
First Name
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Son
Daughter
Step Child
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Half Sister
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Is Dependent a Student?
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Dependent
7
First Name
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Son
Daughter
Step Child
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Dependent
8
First Name
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Son
Daughter
Step Child
Half Brother
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Sister
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Is Dependent a Student?
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Is Dependent Disabled?
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Dependent
9
First Name
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Date of Birth
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Son
Daughter
Step Child
Half Brother
Half Sister
Stepbrother
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Niece
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Parent
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Sister
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Uncle
None
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Is Dependent a Student?
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Yes
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Is Dependent Disabled?
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Dependent
10
First Name
Middle Name
Last Name
Date of Birth
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Type of Relationship
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Son
Daughter
Step Child
Half Brother
Half Sister
Stepbrother
Stepsister
Foster Child
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Niece
Grandchild
Grandparent
Parent
Brother
Sister
Aunt
Uncle
None
Other
Is Dependent a Student?
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Yes
No
Is Dependent Disabled?
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Yes
No
Dependent
11
First Name
Middle Name
Last Name
Date of Birth
Social Security Number
Type of Relationship
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Son
Daughter
Step Child
Half Brother
Half Sister
Stepbrother
Stepsister
Foster Child
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Niece
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Parent
Brother
Sister
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Uncle
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Is Dependent a Student?
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Yes
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Is Dependent Disabled?
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Yes
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Dependent
12
First Name
Middle Name
Last Name
Date of Birth
Social Security Number
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Son
Daughter
Step Child
Half Brother
Half Sister
Stepbrother
Stepsister
Foster Child
Nephew
Niece
Grandchild
Grandparent
Parent
Brother
Sister
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Uncle
None
Other
Is Dependent a Student?
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Yes
No
Is Dependent Disabled?
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Yes
No
Dependent
13
First Name
Middle Name
Last Name
Date of Birth
Social Security Number
Type of Relationship
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Son
Daughter
Step Child
Half Brother
Half Sister
Stepbrother
Stepsister
Foster Child
Nephew
Niece
Grandchild
Grandparent
Parent
Brother
Sister
Aunt
Uncle
None
Other
Is Dependent a Student?
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Yes
No
Is Dependent Disabled?
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Yes
No
Dependent
14
First Name
Middle Name
Last Name
Date of Birth
Social Security Number
Type of Relationship
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Son
Daughter
Step Child
Half Brother
Half Sister
Stepbrother
Stepsister
Foster Child
Nephew
Niece
Grandchild
Grandparent
Parent
Brother
Sister
Aunt
Uncle
None
Other
Is Dependent a Student?
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Yes
No
Is Dependent Disabled?
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Yes
No
Dependent
15
First Name
Middle Name
Last Name
Date of Birth
Social Security Number
Type of Relationship
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Son
Daughter
Step Child
Half Brother
Half Sister
Stepbrother
Stepsister
Foster Child
Nephew
Niece
Grandchild
Grandparent
Parent
Brother
Sister
Aunt
Uncle
None
Other
Is Dependent a Student?
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Yes
No
Is Dependent Disabled?
Select One...
Yes
No
Dependent
16
First Name
Middle Name
Last Name
Date of Birth
Social Security Number
Type of Relationship
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Son
Daughter
Step Child
Half Brother
Half Sister
Stepbrother
Stepsister
Foster Child
Nephew
Niece
Grandchild
Grandparent
Parent
Brother
Sister
Aunt
Uncle
None
Other
Is Dependent a Student?
Select One...
Yes
No
Is Dependent Disabled?
Select One...
Yes
No
Dependent
17
First Name
Middle Name
Last Name
Date of Birth
Social Security Number
Type of Relationship
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Son
Daughter
Step Child
Half Brother
Half Sister
Stepbrother
Stepsister
Foster Child
Nephew
Niece
Grandchild
Grandparent
Parent
Brother
Sister
Aunt
Uncle
None
Other
Is Dependent a Student?
Select One...
Yes
No
Is Dependent Disabled?
Select One...
Yes
No
Dependent
18
First Name
Middle Name
Last Name
Date of Birth
Social Security Number
Type of Relationship
Select One...
Son
Daughter
Step Child
Half Brother
Half Sister
Stepbrother
Stepsister
Foster Child
Nephew
Niece
Grandchild
Grandparent
Parent
Brother
Sister
Aunt
Uncle
None
Other
Is Dependent a Student?
Select One...
Yes
No
Is Dependent Disabled?
Select One...
Yes
No
Dependent
19
First Name
Middle Name
Last Name
Date of Birth
Social Security Number
Type of Relationship
Select One...
Son
Daughter
Step Child
Half Brother
Half Sister
Stepbrother
Stepsister
Foster Child
Nephew
Niece
Grandchild
Grandparent
Parent
Brother
Sister
Aunt
Uncle
None
Other
Is Dependent a Student?
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Yes
No
Is Dependent Disabled?
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Yes
No
Dependent
20
First Name
Middle Name
Last Name
Date of Birth
Social Security Number
Type of Relationship
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Son
Daughter
Step Child
Half Brother
Half Sister
Stepbrother
Stepsister
Foster Child
Nephew
Niece
Grandchild
Grandparent
Parent
Brother
Sister
Aunt
Uncle
None
Other
Is Dependent a Student?
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Yes
No
Is Dependent Disabled?
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Yes
No
Address / Misc.
Address
Address 2
Zip Code
City
State
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AL - Alabama
AK - Alaska
AZ - Arizona
AR - Arkansas
CA - California
CO - Colorado
CT - Connecticut
DE - Delaware
DC - District Of Columbia
FL - Florida
GA - Georgia
HI - Hawaii
ID - Idaho
IL - Illinois
IN - Indiana
IA - Iowa
KS - Kansas
KY - Kentucky
LA - Louisiana
ME - Maine
MD - Maryland
MA - Massachusetts
MI - Michigan
MN - Minnesota
MS - Mississippi
MO - Missouri
MT - Montana
NE - Nebraska
NV - Nevada
NH - New Hampshire
NJ - New Jersey
NM - New Mexico
NY - New York
NC - North Carolina
ND - North Dakota
OH - Ohio
OK - Oklahoma
OR - Oregon
PA - Pennsylvania
RI - Rhode Island
SC - South Carolina
SD - South Dakota
TN - Tennessee
TX - Texas
UT - Utah
VT - Vermont
VA - Virginia
WA - Washington
WV - West Virginia
WI - Wisconsin
WY - Wyoming
Phone/Cellular Number
*
Cellular Provider
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ACS Alaska
ACS Wireless
AIO Wireless
Alltel
AT&T
Bellsouth
Bellsouth Mobility
Boost Mobile
Carolina West
CBeyond
Cellular One
Cellular One Texas
Cellular South
Cincinnati Bell
Cleartalk
Cricket(SMS)
Cricket(MMS)
CSpire
Edge
GCI
Google Voice
Go Smart Mobile
H20 Wireless
Inland
Metro PCS
Metro PCS 2
Mobileone
Mobi PCS
Nextel
Pocket
Project FI
Qwest Mobile
Republic Wireless
Simple Mobile
Sprint PCS
Surewest Comm
T-Mobile
Thumb
US Cellular
Verizon
StraightTalk
Page Plus Cellular
Virgin Mobile
How did you hear about us?
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Referral
Prior Client
Name of Referral
Referral ID
Coupon
Coupon
Contact Information
Email Address
*
Preferred Location
*
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Dricka Carter
Bruce Carter
Asia Gill
Ashley Wilson
Candria Bazile
Daisha Oshunremi
Dionne Fleming
Lexus Johnson
Sharron Bartholomew
Shelquita Jackson
Sparkle Lewis
Payment Options
Withhold Fees from Refund
Pay at Time of Filing
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