Form
5129
(Rev. December 2007)
Questionnaire
—Filing Status, Exemptions, and Standard Deduction
Section I. Taxpayer Data
1. Name(s) and address (exactly as shown on your income tax return)
2. Social Security Number
3. Tax Form Number
4. Spouse’s Social Security Number
5. Tax Year Ending
Section II. Filing Status and Standard Deduction
Please check the appropriate box and answer the corresponding question(s) to show how you intended to file your tax return.
1.
Single
2. Married filing joint return
3.
Married filing separate return
a.
Did your spouse file a tax return for the tax year in Section I above?
. . . . . . .
Yes No Unknown
b.
Please enter your spouse’s Social Security Number in Section I above and print
your spouse’s name here as it appeared on that return
c.
Did you and your spouse live together at any time during the last 6 months of
the year?
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes No
4.
Head of Household (with qualifying dependent)
(During the tax year, you provided more than half the cost of maintaining a household for a qualifying dependent.)
a.
If the qualifying person is your child, but is being claimed by the other parent,
enter this child’s name here:
. . . . . . . . . . . . . . . . . . . . . . . . . .
b. At the end of the tax year in Section I, above, you were:
Unmarried Widowed Legally Separated Married to a Nonresident Alien
You claimed your married child, grandchild, great-grandchild, etc., to include stepchild or adopted child who qualifies
as your dependent.
You claimed your married child, grandchild, great-grandchild, etc., adopted child, or stepchild who is not claimed
as a dependent, due to your divorce or separation from the other parent who is claiming the child as a dependent.
You claimed your foster child who is qualified as your dependent.
You claimed any other relative who is qualified as your dependent.
c. The household mentioned in Item 4a, above, was:
Your household.
The home you maintained for your parent who can be claimed as your dependent.
d.
Did you and your spouse live together at any time during the last 6
months of the tax year?
. . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes No
5. Qualifying widow(er) with dependent child
. . . . . . . . . . .
What year did your spouse die?
Section Ill. Exemptions for Dependents and Standard Deduction
Please give complete information below for each person you claimed as a dependent on your return for the tax year shown in Section 1.
The names and Social Security Numbers you provide below must be written as they appear on the Social Security Card(s) issued by the Social
Security Administration. If you need additional space or have made changes to any of these items, please use the back of this form to continue
and/or explain your entries.
1. First and Last Name 2. Social Security Number
3. Dependent’s
Relationship to You
4. Check box if dependent
qualifies for Child Tax Credit
5. Were you 65 or over at the end of the tax year shown in Section I, above?
. . . . . . . . . . . . .
Yes No
6. Were you blind at the end of the tax year?
. . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
7. Was your spouse 65 or older at the end of the tax year?
. . . . . . . . . . . . . . . . . . . . .
Yes
No
8. Was your spouse blind at the end of the tax year?
. . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
9. Did you intend to claim an exemption for your spouse?
. . . . . . . . . . . . . . . . . . . . . .
Yes
No
10. Did your spouse have any gross income for the tax year?
. . . . . . . . . . . . . . . . . . . . .
Yes
No
11. Can you be claimed as a dependent on another person
’
s return for the tax year?
. . . . . . . . . .
Yes
No
12. Can your spouse be claimed as a dependent on another person
’
s return for the tax year?
. . . . . .
Yes
No
Sign here
(if filing jointly,
both must sign)
Under penalties of perjury, I declare that I have examined this statement and to the best of my knowledge and belief, it is true,
correct, and complete.
Your Signature Spouse’s Signature Date
Form
5129
(Rev. 12-2007)
Cat. No. 27391O
Department of the Treasury–Internal Revenue Service
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