Head of Household Questionnaire

HEAD OF HOUSEHOLD QUESTIONNAIRE
Tax Payers Name *

First Name Last Name
Monthly Income
Please enter the amounts you paid for the following household expenses
Property Taxes
Rent
Mortgage Interest
Utilities
Repairs
Groceries/Food
Other Expenses
Please do not count any money received under any governmental/public assistance/welfare/SNAP (food stamps) in the amount that you paid.

Taxpayer has provided all answers to the above questions to be true and correct to the best of the taxpayer's knowledge. Taxpayer has been informed that claiming a dependent for HOH or other can result in an audit, fines and penalties if information provided to the prepaper is incorrect.
Primary Taxpayer's Signature

Clear
Date

Month Day Year
Date
Should be Empty:

HEAD OF HOUSEHOLD QUESTIONNAIRE