DEPENDENTS 
(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)
​

• 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:

                     Utility Bills                   Grocery Receipts               Rent Receipts or Mortgage Interest                   Property Tax Bills                      Other Household Bills 

• Are any of your dependents filing a tax return?                                                                                                                                                                     YES    /     NO     

​              If Yes, provide details: ____________________________________________________________________________________________________

•  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