Validation Form
Earned Income Credit (EIC), Child Tax Credit (CTC) & Head of Household Filing Status (HOH)
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
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Your Tax Preparer's Name
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First Name
Last Name
Your Tax Preparer's E-mail is Required to Have Them Receive a Copy of This Form
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Please Click on the Acknowledgments & Sign If You Agree
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I acknowledge that the information I provided to my tax preparer about my dependent(s) for my tax return, is true and accurate.
I have verified my dependent(s) information that has been entered into my tax return in reference to the Earned Income Credit (EIC) and Child Tax Credit (CTC) that resulted in the info I provided.
CHECK ALL THAT APPLY: To satisfy IRS due diligence requirements, as your tax preparer, I'm required to document which records you could provide if requested to substantiate your dependent’s RELATIONSHIP for the months reported on your tax return.
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Birth Certificate
Adoption Records
Court Guardianship Papers
Foster Placement Letter
Legal Custody Papers
CHECK ALL THAT APPLY: To satisfy IRS due diligence requirements, as your tax preparer, I'm required to document which records you could provide if requested to substantiate your dependent’s RESIDENCY for the months reported on your tax return.
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Health Insurance Form 1095-A, B or C with each dependent's name and your address at the time
School Records with each dependent's name and your address at the time
Child/Day Care Statements with each dependent's name and your address at the time
Lease/Landlord Statement with each dependent's name and your address at the time
Health Care Provider Statement with each dependent's name and your address at the time
Medical Records with each dependent's name and your address at the time
Placement Agency Statements
Letter From Social Service Agency
Letter From Clergyman
Indian Tribal Official Statement
Employer Statement
Court Documents that list the shared address
Other-Specify below
CHECK ALL THAT APPLY: To satisfy IRS due diligence requirements for Head of Household (HOH), we are required to document which records you could provide if requested to substantiate the dependent’s RELATIONSHIP & RESIDENCY for at least 6 months of the year reported on your tax return. Please check all that apply.
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Birth certificates or other official documents of birth
Marriage Certificates
Letter from an authorized Adoption Agency
Letter from the authorized Placement Agency
Applicable court document that verify your relationship to the child
Note: IRS can’t accept documents signed by someone related to you
Other: Please Specify
Client Signature Acknowledgement (sign with your mouse)
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Spouse's Signature Acknowledgement (if applicable)
Client Signature Acknowledgement (sign with your mouse)
Spouse's Signature Acknowledgement (if applicable)
Last 4 digits of your social security number
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