New EITC Questionnaire

EITC Questionnaire

Taxpayer Information
Taxpayer's Full Name*

First NameMiddle InitialLast Name

Dependent Information
Dependent's Full Name
Dependent's Date of Birth

MonthDayYear
Date
Relationship of Dependent

SonDaughterStepsonStepdaughterFoster ChildGrandchildNieceNephewBrotherSisterStepbrotherStepsisterAuntUncleParentGrandparentOther
Is the dependent related to you?
Did the dependent live in your household the entire year?
Is the dependent your child?
Please select one of the following options

Dependent is under 19 years of ageDependent is under 24 years of age and is a full-time student (That is, they are in school for at least 5 months of the year)Dependent is any age and is totally and permanently disabled
Please provide proof of the dependent's disability status (e.g., a doctor's letter certifying the dependent is totally and permanently disabled)

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Is the child a citizen or national of the United States?
Why are the child's parent's not claiming the child?
Is the child married?
Will s/he be filing a joint return with his/her spouse?
Did the child live with you more than six (6) months of the year?
Please provide proof of your address as the child's address (e.g., school records, medical records, child care records, etc.)

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Can anyone else claim the child lived with them for more than six (6) months of the year?
If you are filing as Single or as Head of Household, does anyone in your household earn more money than you do?
Did the dependent earn more than four thousand dollars ($4,000.00) in the year?
Did you provide more than 50% of the financial support for the dependent listed above?
Do you want to list this dependent as the Head of Household?

Acknowledgment & Signature
You agree that your typed name below is the same as your legal signature and that the information you entered above is true and correct to the best of your knowledge.
Date Signed*

MonthDayYear
Date
Taxpayer's Full Name*
Should be Empty: