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Utah State Tax Commission
210 North 1950 West - Salt Lake City - Utah 84134 - Telephone (801) 297-2200
TC-805
Rev. 1/09
Collection Information For Individuals
Agent’s name
2. Home Telephone Number
1. Taxpayers’ Names and Addresses (including county)
3. Marital Status
4. Social Security number
a. Taxpayer:
b. Spouse:
Section One: Employment Information
5. Taxpayer’s Employer or Business Name and Address
6. Business Telephone
7. Occupation
8. Paydays
9. Type
Partner
Sole
Employee
10. Spouse’s Employer or Business Name and Address
12. Occupation
11. Business Telephone
13. Paydays
14. Type
Partner
Sole
Employee
Section Two: Personal Information
15. Name, Address and Telephone Number of Next of Kin or Other Reference
16. Age and Relationship of Dependents (excluding husband and wife in your household)
17. Number of Exemptions
Claimed on W-4.
18. a. Taxpayer’s Date of Birth
b. Spouse’s Date of Birth
Section Three: General Financial Information
19. Latest Filed State Income
20. Adjusted Gross Income
Tax Return (Tax Year)
21. Bank Accounts (including savings and loans, credit unions, IRA and retirement plans,
certificates of deposit, money market accounts, savings bonds, etc.)
Type of
Account
Balance
Name of Institution
Address
Number
Account
$
$
0.00
Total
DO NOT mail with your tax return. To insure proper processing, mail separately to: Taxpayer Services Division, 210 North 1950 West, SLC, UT 84134