Sworn Statement of Residency

What Tax Year are you filing?

Name of the Parent(s) or Guardian(s):

Dates the dependent(s) lived with you in the tax year (Example Jan 1-Dec 31)

Address(es) that your dependents lived with you in the tax year:

List all dependent(s) that lived with you from your Tax Return:

1.
2.
3.
4.

By checking this box, I herby affirm under penalty of perjury that the facts set forth in this statement are true. I'm certifying that the dependent(s) listed above that I am claiming on my tax return has lived with me for more that 6 months in the tax year at the address(es) listed. If audited by the IRS for Earned Income Tax Credit, Head of Household, or Child Tax Credit, I would be able to provide the document(s) below to prove residence of my dependents:

List Other Document

Taxpayer Full Name

Taxpayer Signature

Clear

Spouse Full Name (If filling jointly)

Spouse Signature (if filling jointly)

Clear

Date