EFTA01222063.pdf

Personal Information Worksheet 2017 I. Keep for your records QuickZoom to another copy of Personal Information Worksheet QuickZoom to Federal Information Worksheet Part I - First name. • • Middle initial .Last name • • Suffix Social security no. . . Member of U.S. Armed Forces in 2017?=I— I Yes No Date of birth (mm/ddiyyyy) age as of 1-1-2018 Occupation . . . . Daytime phone. • • • Ext Marital status . • • If widowed, check the appropriate box for the year yourspouse died: After 2017 im•r- 1 2017 . 2016 . 01 I 2015 . Before 2015 . P.M Are you retired on total and permanent disability? (for Schedule R, see Help). .9 Yes No Check if this person is legally blind I. Yes No If deceased, enter the date of death ► (mmidd/yyyy) Were you under the age of 16 as of 1-1-2018 and this is the first year you are filing a tax return? Yes I- I No Do you want $3 to go to Presidential Election Campaign Fund? CI Yes C No Part II — Questions for Individuals Who Could Be Or Are Dependents of Another Taxpayer 1 Can someone (such as your parent) claim you as a dependent? Yes No 2 If you answered 'Yes' to question 1, are you actually claimed as a dependent on that person's tax return? Questions 3 through 5 are only required for individuals who claim the -0 Yes 140 American Opportunity Credit. 3 Were you a full-time student during any part of five months during 2017? ► Yes No 4 Did your earned income exceed one-half of your support? ► Yes No 5 Was at least one of your parents alive on December 31, 2017? ► Yes No Part III — Enter this person's state of residence as of December 31, 2017 Check the appropriate box: This person is a resident of the state above for the entire year This person is a resident of the state above for only part of year Date this person established residence in state above ► In which state (or foreign country) did this person reside before this change? Part IV — Dependent Care Expenses Qualified dependent care expenses incurred and paid for this person in 2017 Unreimbursed medical expenses paid for qualifying person in 2017 Employment taxes paid for dependent care providers in 2017 Full-time student for 5 calendar months during 2017? Disabled person who was not physically or mentally capable of self-care? This person is a qualifying person for the child and dependent care credit i. . . Yes Yes Yes Li No No No Part VI - Healthcare Coverage Does coverage in prior year qualify January and February for eligibility for short gap exemption? See help for additional details. Yes No Prior year covered or exempt other than short gap exemption for November and December, supports answer to January and February eligible for short gap exemption above. Check if covered or exempt (other than shod gap) for prior year November Check if covered or exempt (other than shod gap) for prior year December Check the appropriate box below to indicate the healthcare coverage for this person. Select 12 months if they were covered all year, select the individual months if they were not covered all year and leave blank if they did not have minimum essential during any month of the year. 12 misilhs BIJ M ! I Awl pAyi en, IAtAl pcii m it:Htt Nov Deci EFTA01222063 Enter any Marketplace-granted coverage exemption for this person below: Exemption Certificate Number Exemption Start Month Exemption End Month Enter any other insurance coverage exemption requested for this person below: Exemption Type I Check Full Year or Months Exempt for Each Type Jan Feb Mar Apr May Jun Jul Aug 1 Sep Oct I Nov Dec IFull Year . . . ..I ' 1 1 1 1 1 1 1 1 1 1 I 1 _ I 1 1 1 1 1 1 IFull Year . . . .. 1 1 1 1 1 1 1 1 1 1 1 I I 1 1 1 1 1 1 IFull Year . . . .. 1 1 1 1 1 1 1 1 1 1 1 I 1 1 1 1 1 1 1 1 Healthcare coverage information has been completed for this person. a EFTA01222064