DEPENDENTS
(ATTACH PROOF OF MEDICAL INSURANCE (1095) OR OTHER DOCUMENTATION)
(ATTACH PROOF OF MEDICAL INSURANCE (1095) OR OTHER DOCUMENTATION)
NAME:_________________________________________________________________________DATE OF BIRTH______________________
RELATIONSHIP____________________________________SOCIAL(if we don't already have)________________________________________
NUMBER OF DAYS WITH YOU DURING CURRENT TAX YEAR_______________INCOME____________________FULL-TIME STUDENT? YES / NO
COMMENTS_______________________________________________________________________________________________________
NAME:_________________________________________________________________________DATE OF BIRTH______________________
RELATIONSHIP____________________________________SOCIAL(if we don't already have)________________________________________
NUMBER OF DAYS WITH YOU DURING CURRENT TAX YEAR_______________INCOME____________________FULL-TIME STUDENT? YES / NO
COMMENTS_______________________________________________________________________________________________________
NAME:_________________________________________________________________________DATE OF BIRTH______________________
RELATIONSHIP____________________________________SOCIAL(if we don't already have)________________________________________
NUMBER OF DAYS WITH YOU DURING CURRENT TAX YEAR_______________INCOME____________________FULL-TIME STUDENT? YES / NO
COMMENTS_______________________________________________________________________________________________________
NAME:_________________________________________________________________________DATE OF BIRTH______________________
RELATIONSHIP____________________________________SOCIAL(if we don't already have)________________________________________
NUMBER OF DAYS WITH YOU DURING CURRENT TAX YEAR_______________INCOME____________________FULL-TIME STUDENT? YES / NO
COMMENTS_______________________________________________________________________________________________________
NAME:_________________________________________________________________________DATE OF BIRTH______________________
RELATIONSHIP____________________________________SOCIAL(if we don't already have)________________________________________
NUMBER OF DAYS WITH YOU DURING CURRENT TAX YEAR_______________INCOME____________________FULL-TIME STUDENT? YES / NO
COMMENTS_______________________________________________________________________________________________________
(ATTACH SEPARATE SHEET IF MORE DEPENDENTS)
RELATIONSHIP____________________________________SOCIAL(if we don't already have)________________________________________
NUMBER OF DAYS WITH YOU DURING CURRENT TAX YEAR_______________INCOME____________________FULL-TIME STUDENT? YES / NO
COMMENTS_______________________________________________________________________________________________________
NAME:_________________________________________________________________________DATE OF BIRTH______________________
RELATIONSHIP____________________________________SOCIAL(if we don't already have)________________________________________
NUMBER OF DAYS WITH YOU DURING CURRENT TAX YEAR_______________INCOME____________________FULL-TIME STUDENT? YES / NO
COMMENTS_______________________________________________________________________________________________________
NAME:_________________________________________________________________________DATE OF BIRTH______________________
RELATIONSHIP____________________________________SOCIAL(if we don't already have)________________________________________
NUMBER OF DAYS WITH YOU DURING CURRENT TAX YEAR_______________INCOME____________________FULL-TIME STUDENT? YES / NO
COMMENTS_______________________________________________________________________________________________________
NAME:_________________________________________________________________________DATE OF BIRTH______________________
RELATIONSHIP____________________________________SOCIAL(if we don't already have)________________________________________
NUMBER OF DAYS WITH YOU DURING CURRENT TAX YEAR_______________INCOME____________________FULL-TIME STUDENT? YES / NO
COMMENTS_______________________________________________________________________________________________________
NAME:_________________________________________________________________________DATE OF BIRTH______________________
RELATIONSHIP____________________________________SOCIAL(if we don't already have)________________________________________
NUMBER OF DAYS WITH YOU DURING CURRENT TAX YEAR_______________INCOME____________________FULL-TIME STUDENT? YES / NO
COMMENTS_______________________________________________________________________________________________________
(ATTACH SEPARATE SHEET IF MORE DEPENDENTS)
- Are you able to provide definitive proof (and keep documents for 4 years) that you are eligible to claim your dependents if audited? YES / NO
- Have you ever had any credits related to your dependents disallowed or reduced? YES / NO
- Circle items that you can provide to the IRS in order to substantiate you paid more than half the cost of maintaining your home:
- Are any of your dependents filing a tax return? YES / NO
- To your knowledge is anyone else (such as a non-custodial parent, etc) claiming any of the tax benefits for any of these dependents? YES / NO
Proudly powered by Weebly