EIC/CTC/ACTC/ODC/AOTC/HOH Qualifier Form
*Tax Preparers are REQUIRED under IRS Code (Treas. Reg. section 1.6695-2(b)(3)) to inquire about any information regarding EIC/CTC/ACTC/HOH/ODC/AOTC
Name
First Name and Middle Initial
Last Name
Spouse
First Name and Middle Initial
Last Name
Filing Status
Head of Houesehold
Single
Married filing Jointly
Married filing Seperate
Qualifying Windower
Dependents
Rows
Dependent Name
DOB
SSN
Relationship
Months in Your Home
Full or Shared Custody
1
2
3
4
1. If Last Name(s) Is/Are Different from Taxpayer(s) Name Explain Why:
Different Father/Mother
Legal court
Grandparent
Other:
Explain Other if applicable
2. Has the Dependent(s) Lived with the Taxpayer for Over ½ Of the Year?
YES
NO
3. Did you claim the same dependent(s) last year?
YES
NO
4. Has anyone else claimed any dependent(s) within the last 3 years?
YES
NO
5. If so, why?
6. Has the Taxpayer paid over ½ of the total expenses of the dependents for the year?
YES
NO
7. For dependents that are shared custody, can the tax payer provide document to the IRS to prove the dependent lived with them for more than ½ of the year and paid for over ½ total expenses?
YES
NO
8. Why is the parent not claiming the Qualifying Child?
Deceased
Incarcerated
Medical / Court Action
Financially Incapable of Support N/A
N/A
Qualifying Documents must show: • The name of the child's parent or guardian. • The child's home address. The address MUST match the taxpayers. • Dates when the child lived with you.
9. Which of the following document(s) can the taxpayer provide to verify residency if requested by the IRS at a later time? (Please select all that apply)
School
Healthcare or medical provider
Placement agency official
Social service agency
Employer
Indian tribal official
Landlord or property manager • Church, synagogue, mosque or other place of worship
10. IRS suggests average yearly income to be around $6000 per dependent. If its lower, does taxpayer have documents to prove they covered over ½ total expenses:
YES
NO
11. Was the taxpayer married at all during the tax year?
YES
NO
12. Was the taxpayer married as of December 31st, 2025?
YES
NO
13. If any dependents are not taxpayers’ children, are the dependents parents’ aware taxpayer is claiming them? (LEAVE BLANK IF YOU ARE THE DEPENDENTS PARENTS)
YES
NO
I (Print Name) acknowledge that the taxpayer has asked me relevant information to certify that I am able to claim all listed dependent(s). Any documents I have, or claim to have, can be supplied to the Tax Preparer or the IRS at a later date if requested.
First Name
Last Name
Taxpayer Signature
Date
-
Month
-
Day
Year
Date
Spouse Signature
Date
-
Month
-
Day
Year
Date
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Schedule C Affidavit
Business Name:
Years In Operation:
Did you file a Schedule C for this business last year?
YES
NO
Did the business earn any profit this year?
YES
NO
Did the business earn any profit last year?
YES
NO
If answered no to both, does the taxpayer plan to continue the business?
YES
NO
N/A
If yes, does the taxpayer have other income to support business losses?
YES
NO
N/A
Has the business produced income within the last 3 years?
YES
NO
What type of payments does this business receive?
CASH
CHECK
CREDIT/DEBIT
DIRECT DEPOSIT
If this business accepts Credit/Debit & made over $2k, did they receive a 1099K?
YES
NO
N/A
Is the Taxpayer able to provide receipts of all transactions now, or at a later date?
YES
NO
Does the business have expenses?
YES
NO
If no, explain why:
Business Name (2):
Years In Operation:
Did you file a Schedule C for this business last year?
YES
NO
Did the business earn any profit this year?
YES
NO
Did the business earn any profit last year?
YES
NO
If answered no to both, does the taxpayer plan to continue the business?
YES
NO
N/A
If yes, does the taxpayer have other income to support business losses?
YES
NO
N/A
Has the business produced income within the last 3 years?
YES
NO
What type of payments does this business receive?
CASH
CHECK
CREDIT/DEBIT
DIRECT DEPOSIT
If this business accepts Credit/Debit & made over $2k, did they receive a 1099K?
YES
NO
N/A
Is the Taxpayer able to provide receipts of all transactions now, or at a later date?
YES
NO
Does the business have expenses?
YES
NO
If no, explain why:
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Please use the following page to describe expenses reported on the Schedule C worksheet.
I confirm that the information put forth on the Schedule C of my tax return is information that I supplied to my tax preparer. This information is based on records that I currently have or can reconstruct showing both my income and expenses from my self-employment. My tax preparer asked me questions about my income and expenses, to help me to reconstruct my records; however, all numbers were supplied by me. The information reported on my Schedule C is true and correct to my best understanding.
Signature: under penalty of perjury
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
If you feel that your tax preparer unduly influenced your reporting of your income or expenses, please contact IRS customer service at 800.829.1040 to report any misconduct.
Advertising:
Vehicle Mileage:
Business miles:
Commuting miles:
Other purposes:
Other purposes:
Vehicle Actual Expenses
Gas, oil, repairs, etc. :
Vehicle rentals:
Commissions and Fees:
Contract Labor:
Depletion:
Depreciation:
Employee benefit programs:
Insurance (other than health):
Interest
Mortgage (paid to banks, etc.):
Other Legal and professional services:
Office expense Pension and profit share:
Rent or lease
Rental-Vehicles, machinery:
Other Business Property:
Repairs and maintenance:
Supplies (not part of goods sold):
Taxes and licenses:
Travel:
Deductible meals:
Fully deductible meals included above:
Utilities Wages (less Employment Credits):
Should be Empty: