Relationship to dependent: blanks
General Questions:
Child #1 Name First Name Last Name Date of Birth: Date This child’s relationship to you: How many months in the calendar year 2021 did this child live with you? Do you have any evidence to prove this child lived in your home such as school records, medical bills, etc? Yes No If this child is a student: Choose one Preschool Elementary High School College College Single Parent Questions:Where is the child’s other parent? Why is the other parent not claiming child? Who watches the child while you are at work? Daycare Expenses: $ Are the other parent’s earnings more than yours? Yes No
Child #2 Name First Name Last Name Date of Birth: Date This child’s relationship to you: How many months in the calendar year 2021 did this child live with you? Do you have any evidence to prove this child lived in your home such as school records, medical bills, etc? Yes No If this child is a student: Choose one Preschool Elementary High School College College Single Parent Questions:Where is the child’s other parent? Why is the other parent not claiming child? Who watches the child while you are at work? Daycare Expenses: $ Are the other parent’s earnings more than yours? Yes No
Child #3 Name First Name Last Name Date of Birth: Date This child’s relationship to you: How many months in the calendar year 2021 did this child live with you? Do you have any evidence to prove this child lived in your home such as school records, medical bills, etc? Yes No If this child is a student: Choose one Preschool Elementary High School College College Single Parent Questions:Where is the child’s other parent? Why is the other parent not claiming child? Who watches the child while you are at work? Daycare Expenses: $ Are the other parent’s earnings more than yours? Yes No
Who Pay's? 1. Rent/Mortgage Me Parents Boyfriend/Girlfriend Other 2. Home Insurance Me Parents Boyfriend/Girlfriend Other 3. Medical Bills Me Parents Boyfriend/Girlfriend Other 4. Food Me Parents Boyfriend/Girlfriend Other 5. Utilities Me Parents Boyfriend/Girlfriend Other
Name of Financial Institution: blanks* Routing Number:blank* Account Number: * Checking Savings* Authorized Signature (primary) Signature* Date: Date*