Fill Out Self-Employed Data Form

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Triangle Tax Self-Employed Data Form

First Namefirst name

Middle InitialMiddle Initial

Last Namelast name

Social Security NumberSocial Security Number

Spouse First NameSpouse First Name

Spouse Middle InitialSpouse Middle Initial

Spouse Last NameSpouse Last Name

Spouse SSNSpouse SSN

Addressaddress

City, State, Zip codeCity, State, Zip code

Taxpayer Emaila valid email

Spouse EmailSpouse Email

Taxpayer OccupationTaxpayer Occupation

Spouse OccupationSpouse Occupation

Taxpayer Phone NumberTaxpayer Phone

Spouse Phone NumberSpouse Phone Number

Taxpayer Date of Birth (mmddyyyy)Taxpayer Date of Birth (mmddyyyy)

Spouse Date of Birth (mmddyyyy)Spouse Date of Birth (mmddyyyy)

Did the taxpayer, spouse, or any dependent receive insurance through the Marketplace?Choose one

YesNo

Filing StatusChoose one

SingleMarriedMarried Filing SeparatelyHead of Household

Dependent 1: First/Last NameDependent 1: First/Last Name

Dependent 1: SSNDependent 1: SSN

Dependent 1: DOBDependent 1: DOB

Dependent 1: Relationshipyour full name

Dependent 2: First/Last NameDependent 2: First/Last Name

Dependent 2: SSNDependent 2: SSN

Dependent 2: DOByour full name

Dependent 2: RelationshipDependent 2: Relationship

Dependent 3: First/Last NameDependent 3: First/Last Name

Dependent 3: SSNDependent 3:SSN

Dependent 3: DOBDependent 3: DOB

Dependent 3: Relationshipyour full name

Dependent 4: First/Last NameDependent 4: First/Last Name

Dependent 4: SSNDependent 4: SSN

Dependent 4: DOBDependent 4: DOB

Dependent 4: RelationshipDependent 4: Relationship

Dependent 5: First/Last NameDependent 5: First/Last Name

Dependent 5: SSNDependent 5: SSN

Dependent 5: DOBDependent 5: DOB

Dependent 5: RelationshipDependent 5: Relationship

Dependent 6: First/Last NameDependent 6: First/Last Name

Dependent 6: SSNDependent 6: SSN

Dependent 6: DOBDependent 6: DOB

Dependent 6: RelationshipDependent 6: Relationship

Bank Information (For Direct Deposit Only)

Name of BankName of Bank

Account NumberAccount Number

Bank Routing NumberBank Routing Number

Bank account type

CheckingSaving

Driver's License #Driver's License #

Driver's License StateDriver's License State

Driver's License Issue DateDriver's License Issue Date

Driver's License Issue ExpirationDateDriver's License Issue ExpirationDate

Taxpayer's Identity Theft PINRouting Number

Business Information

Business NameBusiness Name

Primary Product/ServicesPrimary Product/Services

Business EmailBusiness Email

Employer Identification Number (EIN)Employer Identification Number (EIN)

Total Sq Ft if HomeTotal Sq Ft if Home

Sq Ft Used for BusinessSq Ft Used for Business

Business Miles Driven for YearBusiness Miles Driven for Year

Gross Receipts for Year (1099's, CashApp, Square, Uber, Door Dash, etc)Gross Receipts for Year (1099's, CashApp, Square, Uber, Door Dash, etc)

AdvertisingAdvertising

Contract LaborContract Labor

Insurance (other than health)Insurance (other than health)

Legal & Professional ServicesLegal & Professional Services

Office ExpensesOffice Expenses

Rent and LeaseRent and Lease

Vehicle/Equipment RentalVehicle/Equipment Rental

Repairs & MaintenanceRepairs & Maintenance

SuppliesSupplies

Taxes and LicensesTaxes and Licenses

TravelTravel

MealsMeals

UtilitiesUtilities

WagesWages

Cell PhoneCell Phone

Other Expenses (expense/expense amountOther Expenses (expense/expense amount

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