Sworn Statement of Residency
Name of Parent(s) or Guardian(s):
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First Name
Last Name
Dates the dependent(s) lived with you in calendar year {2025}:
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Example: January 1 - December 31
Address that your dependent(s) lived at with you in calendar year {2025}:
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
List all dependent(s) that lived with you from your tax return. {Dependent 1}
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First Name
Last Name
List all dependent(s) that lived with you from your tax return. {Dependent 2}
First Name
Last Name
List all dependent(s) that lived with you from your tax return. {Dependent 3}
First Name
Last Name
I am certifying that the dependents listed above that I am claiming on my {2025} tax return has lived with me at the address above for more than 6 months in {2025} in the United States.
*
Yes
If I was audited by the IRS for EITC, Head of Household, or Child Tax Credit; You are confirming that you are be able to provide one of the document(s) listed to prove residency of my dependents. {Choose One}
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School Records
Medical Records
Daycare Records
Lease Agreement
List Other Documents:
I here by affirm under penalty of perjury that the facts set forth in this statement are true.
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Date
*
-
Month
-
Day
Year
Date
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Should be Empty: