Dependent Information Form Dependent Information Sheet Step 1 of 5 20% DEPENDENTSDEPENDENT NAME D.O.B MM slash DD slash YYYY S.S.N LIVES WITH? YES NO # OF MONTHS DEPENDENT NAME D.O.B MM slash DD slash YYYY S.S.N LIVES WITH? YES NO # OF MONTHS DEPENDENT NAME D.O.B MM slash DD slash YYYY S.S.N LIVES WITH? YES NO # OF MONTHS DEPENDENT NAME D.O.B MM slash DD slash YYYY S.S.N LIVES WITH? YES NO # OF MONTHS DEPENDENTS CREDITSDAYCARE NAME DAY CARE EIN # PAID $ STREET ADDRESS CITY, STATE, ZIP FOR SHARED CUSTODY SITUATIONSGROSS INCOME OF OTHER PERSON $ (TIE BREAKER RULES)HOW MANY OVERNIGHTS DID YOUR DEPENDENT STAY WITH YOU THIS TAX YEAR? HOW MANY OVERNIGHTS WITH THE OTHER PERSON? DO YOU HAVE AN 8332 ON FILE FOR ANY YEARS? YES NO IF SO, PLEASE PROVIDE A COPY OF IT HEAD OF HOUSEHOLD FILING STATUSIF YOU WERE ASKED BY THE IRS, CAN YOU PROVIDE PROOF OF KEEPING UP HOUSEHOLD FOR YOU & YOUR DEPENDENT? YES NO EXAMPLES: RENT, MORTGAGE, GROCERY RECEIPTS, UTILITIESDID ANYONE ELSE LIVE WITH YOU? YES NO NamesNAME?RELATIONSHIPNamesNAME?RELATIONSHIPNamesNAME?RELATIONSHIPNamesNAME?RELATIONSHIPDID ANYONE HELP PAY FOR THE ABOVE LIVING EXPENSES? YES NO IF SO WHAT PORTION / PERCENTAGE? DEPENDENTS NOTESUntitled
