Grant Company, CPA, P.C.

Last Name
First Name
Middle Initial
Social Security #
Occupation
Date of Birth (MM/DD/YY)
E-Mail
Work Phone
Cellular
Fax
Spouse Last Name
Spouse First Name
Spouse Middle Initial
Spouse Social Security #
Spouse Occupation
Spouse Date of Birth (MM/DD/YY)
Spouse E-Mail
Spouse Work Phone
Spouse Cellular
Spouse Fax
Street Address
Apartment or Suite #
City
State
ZIP
Home Telephone (xxx-xxx-xxxx)
Filing Status (check one)	Single Head of Household Married, Filing Separately Married, Filing Jointly Qualifying Widow(er)
Dependent Information: Include First Name, Last Name, Social Security #, Relationship, and DOB
Child Care Information: Include Name, Address, and Tax ID #
Child Care Payment ($)
I affirm that the above children have lived with me for this tax year and are therefore entitled to claim them as exemptions.	Affirm
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