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VA Waitlist Form
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11
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1
Full Name
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Adrienne Whaley
Chastelle Henry
Cherise Comma
Domonique Baxter
Eleanore Marsh
Maurio Stevens
Shynette Carr
Tawana Moore
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Please Select
Adrienne Whaley
Chastelle Henry
Cherise Comma
Domonique Baxter
Eleanore Marsh
Maurio Stevens
Shynette Carr
Tawana Moore
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2
VA Details
Phone Number
Email Address
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Single
Married filing Jointly
Married Filing Separately
Head of Household
Qualifying Widower
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Single
Married filing Jointly
Married Filing Separately
Head of Household
Qualifying Widower
Filing Status
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3
Dependents
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None
1
2
3
4
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Please Select
None
1
2
3
4
Number of dependents
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4
Dependent #1
First Name
Last Name
Relationship
Social Security Number
Date of Birth
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Yes
No
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Yes
No
Disabled
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Yes
No
Please Select
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Yes
No
Provided than 50% support?
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Yes
No
Please Select
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Yes
No
Has this dependent lived with you more than half the year in 2025?
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5
Continuation - Dependent #1
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Yes
No
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Yes
No
Is anyone else claiming the child or allowed to claim the child?
If Yes, please EXPLAIN:
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6
Dependent #2
First Name
Last Name
Relationship
Social Security Number
Date of Birth
Please Select
Yes
No
Please Select
Please Select
Yes
No
Disabled
Please Select
Yes
No
Please Select
Please Select
Yes
No
Provided more than 50% support?
Please Select
Yes
No
Please Select
Please Select
Yes
No
Has this dependent lived with you more than half the year in 2025?
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7
Continuation - Dependent #2
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Yes
No
Please Select
Please Select
Yes
No
Is anyone else claiming the child or allowed to claim the child?
If Yes, please EXPLAIN:
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8
Dependent #3
First Name
Last Name
Relationship
Social Security Number
Date of Birth
Please Select
Yes
No
Please Select
Please Select
Yes
No
Disabled
Please Select
Yes
No
Please Select
Please Select
Yes
No
Provided more than 50% support?
Please Select
Yes
No
Please Select
Please Select
Yes
No
Has this dependent lived with you more than half the year in 2025?
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9
Continuation - Dependent #3
Please Select
Yes
No
Please Select
Please Select
Yes
No
Is anyone else claiming the child or allowed to claim the child?
If Yes, please EXPLAIN:
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10
Dependent #4
First Name
Last Name
Relationship
Social Security Number
Date of Birth
Please Select
Yes
No
Please Select
Please Select
Yes
No
Disabled
Please Select
Yes
No
Please Select
Please Select
Yes
No
Provided more than 50% support?
Please Select
Yes
No
Please Select
Please Select
Yes
No
Has this dependent lived with you more than half the year in 2025?
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11
Continuation - Dependent #4
Please Select
Yes
No
Please Select
Please Select
Yes
No
Is anyone else claiming the child or allowed to claim the child?
If Yes, please EXPLAIN:
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