2021 Earned Income Credit (EIC) 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 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) that resulted in the info I provided.
If the IRS looks at your tax return, what documents will you be able to provide to establish the dependent(s) lived with you for the month's you stated on your return? (check all that apply)
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School Records
Landlord Statement
Health Care Provider Statement
Medical Records
Placement Agency Statements
Social Service Records
Place of Worship
Indian Tribal Official Statement
Employer Statement
Other-Specify below
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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