• HOUSEHOLD EMPLOYEE INCOME AFFIDAVIT

  • Accius Tax Experts (A.T.E.)

  • TAXPAYER INFORMATION

  • Format: (000) 000-0000.

  • SERVICES PROVIDED

  • Check all services performed:
  • Services Performed

  • HOUSEHOLD EMPLOYERS & INCOME RECEIVED

    Please note You can only make $2600 per household
  • Employer 1
  • Date of Last Payment:
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  • Employer 2
  • Date of Last Payment:
     - -
  • Employer 3
  • Date of Last Payment:
     - -
  • Employer 4
  • Date of Last Payment:
     - -
  • Employer 5
  • Date of Last Payment:
     - -

  • Employer 6

  • Date of Last Payment:
     - -

  • Employer 7

  • Date of Last Payment:
     - -

  • Employer 8

  • Date of Last Payment:
     - -

  • INCOME EXPLANATION SUMMARY (REQUIRED)

  • AFFIDAVIT & CERTIFICATION

  • I certify that all information in this affidavit is true and complete to the best of my knowledge. I understand that providing false information may result in penalties under federal or state law. I authorize Accius Tax Experts (A.T.E.) to use this information to prepare my tax return.

  • Date:
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  • Date:
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  • Date:
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  • Should be Empty: