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MAKE AN APPOINTMENT

Welcome to Valparaiso University's VITA Program 2010!

 The Valparaiso University VITA program will be preparing tax returns from February 6th through April 10 at the Valpariaso University School of Law, 656 S. Greenwich Street in the Student Lounge.  Click here for directions to the School of Law.

In order to streamline this process we ask that you first review our eligibility requirements.  Secondly, please complete the form below as completely as possible to ensure prompt and accurate service once you arrive for your appointment. 

Part I: Taxpayer Information
1. YOUR FIRST NAME MI LAST NAME 2. DATE OF BIRTH
3. US CITIZEN OR ALIEN 4. BLIND (LEGALLY) 5. DISABLED 6. OCCUPATION
YesNo YesNo YesNo
7. SPOUSE'S FIRST NAME MI LAST NAME 8. DATE OF BIRTH
9. US CITIZEN OR ALIEN 10. BLIND (LEGALLY) 11. DISABLED 12. OCCUPATION
YesNo YesNo YesNo
13. ADDRESS CITY STATE ZIP
14. Phone Number & Email Address 15. Could you or your spouse be claimed as a dependent on another's income tax return?
Phone:

Email: 		Yes No

16. On December 31st:

Were You:

If married, did you live with your spouse during any part of the last six months of the year?

YesNo

Is your spouse deceased? If yes, provide the date of death. (mm/dd/yyyy)

Part II: Family and Dependent Information – Do not include you or your spouse.

List everyone who lived in your home and outside your home that you supported during the year.

Name (first, last)

Date of Birth (mm/dd/yyyy)

Dependent Relationship

Months Living With You

US Citizen?

Full-time Student
Yes
No		 Yes
No
Yes
No		 Yes
No
Yes
No		 Yes
No
Yes
No		 Yes
No
Yes
No		 Yes
No

Part III. Income – Did you (or your spouse) receive:
Yes No 1. Wages or Salary (include W-2s for all jobs worked during the year)
Yes No 2. Tip income
Yes No 3. Interest/Dividends from: checking or savings account, bonds, CDs, or brokerage account
Yes No 4. State tax refund (may be taxable if you itemized last year)
Yes No 5. Self Employment Income -business, farm, hobby, 1099-Misc or any earned income not reported on W-2
Yes No 6. Alimony income
Yes No 7. Sale of Stock, Bonds or Real Estate
Yes No 8. Disability income
Yes No 9. Pensions, Annuities, and/or IRA distributions
Yes No 10. Unemployment (1099-G)
Yes No 11. Social Security or Railroad Retirement Benefits (1099-SSA or RRB)
Yes No 12. Other Income: Identify

Part IV. Expenses – Did you (or your spouse) make or have:
Yes No 1. Alimony payments (if yes, you must provide the name and SSN of the recipient)
Yes No 2. Contributions to IRA or other retirement account
Yes No 3. Educational expenses for you, your spouse and/or dependents
Yes No 4. Un-reimbursed medical expenses
Yes No 5. Home mortgage payments (interest and taxes – see Form 1098)
Yes No 6. Charitable contributions
Yes No 7. Child/dependent care expenses that allow you (and your spouse -if married) to work
Yes No 8. Any estimated tax payments for this tax year
Yes No 9. Was EIC previously disallowed? (if yes, you may not be eligible for EIC)

Please select a date to have your taxes done:

Please select an alternate date to have your taxes done:




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