Do Your Own Taxes


Personal Information



Dependent(s) (children) Name:


Dependent's Social Security Number

 


Income


Wages: (Your wages are typically reported to you on a W-2 form by your employer.)


Employer’s Name:


Wages (Box 1 of W-2)


Federal Income Tax Withheld (Box 2 of W-2):


Social Security Tax Withheld (Box 4 of W-2):


Medicare Tax Withheld (Box 6 of W-2):


State (Box 15 of W-2):


State Wages (Box 16 of W-2):


State Income Tax (Box 17 of W-2):


Local Income Tax (Box 19 of W-2):


Interest Income: (Your Interest Income is reported to you on a 1099-INT form by your bank and/or financial institution.)

Bank’s Name:


Interest Income (Box 1 of 1099-INT):


Interest on US Savings Bonds (Box 3 of 1099-INT):


Federal Tax Withheld (Box of 1099-INT):


Dividend Income: (Your Dividend Income is reported to you on a 1099-DIV form by the company you are a shareholder of and/or your financial institution.)

Financial Institution’s Name:


Dividend Income (Box 1 of 1099-DIV):


Capital Gains Distribution (Box 2 of 1099-DIV):


Federal Tax Withheld (Box 4 of 1099-DIV):


Foreign Tax Paid (Box 6 of 1099-DIV):


Unemployment Income:

State Refund Check: (Any state refund received for Prior Year Tax Return)

Deductions:

Did you Itemize your deductions on your prior year tax return? yes no

 

 

We will contact you via email or phone to confirm receipt of your information. The following is the fee schedule for the preparation and delivery of your Federal and State Income Tax Returns:

We will contact you via email or phone to confirm receipt of your information. The following is the fee schedule for the preparation and delivery of your Federal and State

Income Tax Returns:

  • Federal and State Return - $60
  • FedEx Shipping and Handling - $15

Total - $75

***Osorio & Cimbal will not be held responsible for the validity or truth of the information you have entered into the above fields. In addition, any information that has not been entered properly or has been left out will not be the responsibility of Osorio & Cimbal.

By submitting this form, I agree to the above terms and further attest to the validity and truth of the above-entered information.

Golden Wealth Solutions, Inc.  
165 S. Union Blvd. Suite #500B 
Lakewood, CO 80228
Phone: 303-456-1913 Fax: 303-463-8421
www.goldenwealthsolutions.com
Check the background of this financial professional on FINRA's BrokerCheck
Check the background of this financial professional on FINRA's BrokerCheck