Boss Ladies Taxes & Business Services

Dependent Care Form – Tax Preparation

Taxpayer Information

First Name:

Last Name:

Email:

Telephone:

Tax Year:

Children / Dependents (List up to 10)

#	First Name	Last Name	Date of Birth	Sex	SSN
1				M / F
2				M / F
3				M / F
4				M / F
5				M / F
6				M / F
7				M / F
8				M / F
9				M / F
10				M / F

Required Attachments (One per Child)

Social Security Card

Birth Certificate

Shot Record

Attach one document for each child listed above.

Required Disclaimers

Each child listed above lived with me for the entire tax year, or I have provided supporting documentation.

Each child listed above lived in the United States for the entire tax year, or I have provided supporting documentation.

Taxpayer Certification

I certify that the information provided on this form is true and complete to the best of my knowledge.

Signature:

Date:

Print Name:

IRS Disclaimer

This form is for tax preparation intake purposes only and is not an official IRS document. Eligibility to claim a dependent or dependent care benefits is determined by IRS rules and may require additional documentation. Providing information on this form does not guarantee approval, acceptance, or refund by the Internal Revenue Service or any state taxing authority.