DEPENDENT #1
(Please Print)
First Name M.I. Last Name Social Security Number Date of Birth Relationship
Child lived with taxpayers?
Yes No
Number of months:
Dependent’s Earned Income: $ Full Time Student?
Yes No
Has this dependent filed a tax return for 2018?
Yes No
Is there another parent who could claim this child as a dependent?
Yes No
If yes, must provide copy of first page of dependent return If yes, who?
Did you provide more than 50% of the financial support of this child?
Yes No
Divorced/Separated: Do you alternate claiming in even/odd years?
Yes No
Child Care Provider (if child under age 13)
Provider’s Name: Provider’s ID# or SS#: Amount Paid for Childcare: $
Provider’s Address, City, State:
TAXPAYER AND SPOUSE SIGNATURES (Required)
Under penalties of perjury, the information provided about my dependent(s) is to my (our) knowledge true and accurate.
Taxpayer’s Signature Date Spouse’s Signature Date
Taxpayer’s
Printed Name:
Spouse’s
Printed Name
DEPENDENT #2
(Please Print)
First Name M.I. Last Name Social Security Number Date of Birth Relationship
Child lived with taxpayers?
Yes No
Number of months:
Dependent’s Earned Income: $ Full Time Student?
Yes No
Has this dependent filed a tax return for 2018?
Yes No
Is there another parent who could claim this child as a dependent?
Yes No
If yes, must provide copy of first page of dependent return If yes, who?
Did you provide more than 50% of the financial support of this child?
Yes No
Divorced/Separated: Do you alternate claiming in even/odd years?
Yes No
Child Care Provider (if child under age 13)
Provider’s Name: Provider’s ID# or SS#: Amount Paid for Childcare: $
Provider’s Address, City, State:
DEPENDENT #3
(Please Print)
First Name M.I. Last Name Social Security Number Date of Birth Relationship
Child lived with taxpayers?
Yes No
Number of months:
Dependent’s Earned Income: $ Full Time Student?
Yes No
Has this dependent filed a tax return for 2018?
Yes No
Is there another parent who could claim this child as a dependent?
Yes No
If yes, must provide copy of first page of dependent return If yes, who?
Did you provide more than 50% of the financial support of this child?
Yes No
Divorced/Separated: Do you alternate claiming in even/odd years?
Yes No
Child Care Provider (if child under age 13)
Provider’s Name: Provider’s ID# or SS#: Amount Paid for Childcare: $
Provider’s Address, City, State:
Changes in Federal Tax Law require Tax Practitioners to adhere to
Due Diligence rules for claiming dependents. In order to comply with
the new law, complete this form in its entirety to claim a dependent.
Dependent’s gross income must be under $4,150 unless they were a
full-time student under the age of 24.
Child Care: Qualifying expense for care which allows you to work, look for
work, or go to school full time. This information must be provided even if
you have dependent care benefits.
PO Box 139
Cicero, IN 46034
317-984-5812
fl
ightax.com
Dependent Worksheet
