This information will be sent to Sergei Miroshnichenko

  Personal Data

First Name* :
Last Name* :
Spouse First Name:
Spouse Last Name:
Street Address:
City:
State:
Zip Code:
Home Phone* :
Work Phone:       Ext: 
Mobil Phone:
E-mail:
Occupation:
Spouse Occupation:

 

  Miscellaneous Info

 
  Source(s) of your Income: W-2            1099-Misc    
  Do you have any self-employee income or loss?  Yes             No
  Did you have any Security Activities (stocks, bonds, etc.)?  Yes             No
  Did you have any Educational Expenses?  Yes             No
  Did you have any Child Care Expenses?  Yes             No
  Do you own a home (condo)?  Yes             No
  Did you and/or you spouse contribute money to the IRA account?  Yes             No
  Did you withdraw money from the Pension Plan?  Yes             No
  Did you make any charitable contribution?  Yes             No
  Did you pay taxes to 2 or more states ?  Yes             No
  Did you change your home address last year?  Yes             No

Additional comments:  

 

   

 

* All fields except First Name, Last Name, and Home Phone are optional

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