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 where your dependent(s) lived with you in the tax year for more than 6 months:

Address *

Street Address

Country

State

City

Postal Code

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

By typing your name and the last 4 digits of your Social Security number, this serves as your electronic signature and confirms that all information entered on this form is true and correct.

Taxpayer Full Name *

Last 4 numbers of your social security number *

Date *