NAME:                                            

Phone: Day                      Evening

Yes

No

1. Did you already file your taxes for 2004? (if yes, not eligible)

2. Are you a U.S. citizen or legal permanent resident of the U.S.? (if no, not eligible)

3. Are you between 25 and 64 years old or between 18 and 24 years old with at least one child? (if no to both, not eligible)

4. Was your 2004 income greater than what appears in the following list? (if yes, not eligible)

Single/head of household with 2 or more children . . $34,458

Single/head of household with 1 child . . $30,338

Single/head of household with no children . . $11,490

Married, filing jointly with 2 or more children . . $35,458

Married, filing jointly with 1 child . . $31,338

Married, filing jointly with no children . . $12,490

5. If you have a dependent, by blood or adoption, is that dependent a U.S. citizen or resident of the U.S.? (if no, not eligible) (If you have no dependent, not applicable.)

6. Do you have an ITIN number generated by the IRS to permit you to prepare your taxes? (if yes, not eligible)

7. Do you have a social security number that allows you to work? (if no, not eligible)

8. Have you lived in the U.S. for over six months? (if no, not eligible)

9. Are you blind? (if yes, not eligible)

10. Did you take money out of your pension, 401k or retirement plan? (if yes, not eligible)

11. Do you have any income from rental property, stocks, annuity distribution or other investment income? (if yes, not eligible)

12. Did you have interest income over $1,500? (if yes, not eligible)

13. Did you (or your spouse, if filing jointly) have W-2s or 1099- MISC? (if no to both, not eligible)

14. Can you be claimed by someone else as a dependent? (if yes, not eligible)

15. Do you plan to itemize your deductions? (if yes, not eligible)

16. Do you own a home? (if yes, not eligible)

17. Are you separated from your spouse? (if yes, not eligible, unless you have dependents and lived apart the last 6 months of 2004)

18. Did you live or work outside of Massachusetts in 2004? (If yes, not eligible)

19. Did you file state taxes in Massachusetts last year? (if no, you must paper file your state taxes)

Can you use a computer and a mouse?

Do you have an email account? (if no, tax-filer will need to paper file or create an email account)

Do you want to use Direct Deposit for your refund? oyes ono

If yes, bring your checkbook or bank statement.
If yes, do you want your refund directed to ochecking or osavings?