Full Name *

Date of birth *

Phone *

Email *

Driver's License #

State Issued

Issue Date

Expiration Date

Occupation *

Company/Employer *

Are you totally and permanently disabled? *

Yes

No

Are you legally blind? *

Yes

No

Spouse Full Name

Spouse Date Of Birth

Phone Number

Spouse Address

Street Address
City
State/Province
Postal/Zip Code

Spouse Occupation

Are they a full-time student?

Yes

No

Are they totally and permanently disabled?

Yes

No

Are they legally blind?

Yes

No

Are they your dependent?

Yes

No

Enter your dependents here

Name
Name
Name
Name
Name

Employment Status *

Are you contributing to 401k or other pre-tax account? *

Yes

No

Is this your first time opening a pre-tax account?

Yes

No

What is the monthly rental amount?

Enter the following expenses total amount

Medical Expenses
Dental Expenses
Insurance Premiums paid
Long Term Care Premiums
Prescription Drugs and Medications
Home Mortgage
Investment Interest
Cash Contributions
Non-Cash Contributions
Unreimbursed Business Expenses
Union Dues
Tax Preparation Fees
Investment Expenses

Total Expenses

Date Signed *

Taxpayer Signature *

Clear