DEPENDENT #1
NAME:   First Name   Last Name   
RELATIONSHIP:   Relationship   
DATE OF BIRTH:   Date of Birth         
SOCIAL SECURITY NUMBER:   SSN   
MONTHS LIVED WITH YOU:   months lived with you   
FULL TIME STUDENT?YES   NO   
DID YOU PROVIDE MORE THAN HALF OF THE SUPPORT?   YES   NO            

DEPENDENT #2
NAME:   First Name   Last Name   
RELATIONSHIP:   Relationship   
DATE OF BIRTH:   Date of Birth         
SOCIAL SECURITY NUMBER:   SSN   
MONTHS LIVED WITH YOU:   months lived with you   
FULL TIME STUDENT?YES   NO   
DID YOU PROVIDE MORE THAN HALF OF THE SUPPORT?   YES   NO            

DEPENDENT #3
NAME:   First Name   Last Name   
RELATIONSHIP:   Relationship   
DATE OF BIRTH:   Date of Birth         
SOCIAL SECURITY NUMBER:   SSN   
MONTHS LIVED WITH YOU:   months lived with you   
FULL TIME STUDENT?YES   NO   
DID YOU PROVIDE MORE THAN HALF OF THE SUPPORT?   YES   NO            

DEPENDENT #4
NAME:   First Name   Last Name   
RELATIONSHIP:   Relationship   
DATE OF BIRTH:   Date of Birth         
SOCIAL SECURITY NUMBER:   SSN   
MONTHS LIVED WITH YOU:   months lived with you   
FULL TIME STUDENT?YES   NO   
DID YOU PROVIDE MORE THAN HALF OF THE SUPPORT?   YES   NO            

DEPENDENT #5
NAME:   First Name   Last Name   
RELATIONSHIP:   Relationship   
DATE OF BIRTH:   Date of Birth         
SOCIAL SECURITY NUMBER:   SSN   
MONTHS LIVED WITH YOU:   months lived with you   
FULL TIME STUDENT?YES   NO   
DID YOU PROVIDE MORE THAN HALF OF THE SUPPORT?   YES   NO            

FEDERAL ESTIMATED PAYMENT(S) MADE:

1. $      Date   Date   
2. $      Date   Date   
3. $      Date   Date   
4. $      Date   Date   

STATE ESTIMATED PAYMENT(S) MADE:
SELECT STATE    Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming    

1. $      Date   Date   
2. $      Date   Date   
3. $      Date   Date   
4. $      Date   Date   

STATE ESTIMATED PAYMENT(S) MADE:
SELECT STATE    Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming    

1. $      Date   Date   
2. $      Date   Date   
3. $      Date   Date   
4. $      Date   Date