Filling Status (1=single, 2=married, 3=MFS,
4=HOH, 5=Widow ........................................................................................................
Check this box if married filing separately
and you lived with spouse at any time during the tax year
............................................
If so, did you live together during the
last six months? ........................................................................................................................
SPOUSE
Social Security Number
Birthdate
Deceased
First Name
Initial
Last Name
Suffix
HOME
Street Address
Apt.
#
City
State
Zip
DEPENDENTS
First
and Last Name
Birthdate
SSN
Relationship
#
of Months
*Dep
Code
EIC
Dep.
Care
Child-Care Provider
S.S.#:
Address
Tel#:
$
I, the undersigned
hereby certify under penalty of perjury that the foregoing
is true and correct; and I (taxpayer) must have all
the document and records as a proof to the internal
revenue service for future examination.
