Household Help Validation Form
TODAYS DATE
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Month
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Day
Year
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Your Name (Tax Payer/Client)
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First Name
Last Name
Spouse's Name (Tax Payer/Client)
First Name
Last Name
Your email where a copy of this form will be sent to you
Your Tax Preparer's Name
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First Name
Last Name
Your Tax Preparer's E-mail (not your email) is Required for Them Receive a Copy of This Form
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Approximately how much was earned this tax year as household help?
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$15,000
Job Duties (click all that apply)
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Childcare/Nanny Services
Cleaning and Housekeeping
Cooking and Food Preparation
Elderly or Disabled Care
Pet Care
Yard Work and Outdoor Maintenance
Home Organization
Errands and Other Assistance
Childcare Nanny/Services Duties (click all that apply)
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Supervising children
Preparing meals and snacks for children
Helping with homework or schoolwork
Driving children to and from school or activities
Engaging in playtime or educational activities
Companionship for children
Other
Cleaning and Housekeeping Duties (click all that apply)
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General cleaning (dusting, sweeping, vacuuming)
Mopping floors
Cleaning bathrooms and kitchens
Washing dishes or loading/unloading dishwasher
Laundry (washing, drying, folding)
Changing bed linens and making beds
Other
Cooking and Food Preparation Duties (click all that apply)
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Meal planning and preparation
Grocery shopping
Packing lunches or meal prep for family members
Other
Elderly or Disabled Care Duties (click all that apply)
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Assisting with bathing or personal hygiene
Helping with mobility (e.g., wheelchair transfers)
Administering medications
Companionship or social engagement
Running errands (e.g., picking up prescriptions, shopping)
Other
Pet Care Duties (click all that apply)
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Walking or exercising pets
Feeding and water for pets
Cleaning up after pets (e.g., litter boxes, accidents)
Companionship for pets
Grooming or bathing pets
Other
Yard Work and Outdoor Maintenance Duties (click all that apply)
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Mowing lawn
Watering plants or gardening
Raking leaves
Snow removal or de-icing walkways
Other
Home Organization Duties (click all that apply)
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Decluttering or organizing closets, cabinets, or storage
Packing or unpacking for moves
Seasonal cleaning (e.g., spring cleaning, holiday prep)
Other
Errands and Other Assistance (click all that apply)
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Running general errands (e.g., dry cleaning, post office)
Assisting with bill payments or household budgeting
Other
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Please Click on the Acknowledgments & Sign If You Agree
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I acknowledge that I reported earning income as a household employee during the tax year but did not provide third-party documentation (e.g., W-2, paystubs, or employer statements).
I acknowledge that the information I provided to my tax preparer about my income is true and accurate to the best of my ability.
If the IRS looks at your tax return, what documents can you provide to establish that you earned income via household help (check all that apply)
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W2
1099
Signed Statement from Employer
Pay Stud
Direct Deposit in Bank Statement
Work Agreement/Contract
None
Other
Other: Please Specify
Client Signature Acknowledgement (sign with your mouse)
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Spouse's Signature Acknowledgement (if applicable)
Last 4 digits of your social security number
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