Name *

First Name

Last Name

Bank Type

Checking Account

Savings Account

Were any credits disallowed or reduced in a prior year? *

Yes

No

Were there any credits disallowed or reduced in a previous year? *

Yes

No

Is the taxpayer (or the taxpayer’s spouse if filing jointly) eligible to be claimed as a dependent on anyone else’s federal income tax return for tax year 2024? *

Yes

No

Is the taxpayer (or spouse) a qualifying child of another person? *

Yes

No

Was the taxpayer (or spouse) a nonresident alien for any part of the year? *

Yes

No

Can the taxpayer be claimed as a dependent on someone else’s return? *

Yes

No

Was the taxpayer over the age of 18 and a full-time student at an eligible educational institution? *

Yes

No

Is the taxpayer blind? *

Yes

No

Is the taxpayer deceased? *

Yes

No

Does the taxpayer wish to contribute $3 to the Presidential Election Campaign Fund? *

Yes

No

Has the taxpayer or spouse served in a combat zone during the current tax year? *

Yes

No

Was the taxpayer or spouse affected by a natural disaster during the current tax year? *

Yes

No

Did the taxpayer receive, sell, or dispose of a digital asset (or financial interest in a digital asset) in the current tax year? *

Yes

No

Does the taxpayer prefer to receive written communications from the IRS in a language other than English? *

Yes

No

Does the taxpayer prefer to receive written communications from the IRS in an accessible format? *

Yes

No

Is the taxpayer treating a nonresident alien or dual-status alien spouse as a U.S. resident for the entire tax year? *

Yes

No

Does the taxpayer/spouse have dependents? (If yes, go to the next section) *

Yes

No