Parent legal guardian FORM
Parent/Legal Guardian Name
I,
certify that I am the legal parent or legal guardian of the dependents listed below.
Dependent 1
Full Name:
Date of Birth:
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Month
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Day
Year
Date
Dependent 2
Full Name:
Date of Birth:
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Month
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Day
Year
Date
Dependent 3
Full Name:
Date of Birth:
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Month
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Day
Year
Date
Dependent 4
Full Name:
Date of Birth:
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Month
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Day
Year
Date
Taxpayer's Name
I authorize to claim the above dependent(s) on their federal and/or state income tax return for the current tax year. I affirm that this authorization is provided voluntarily and that the dependent(s) meet IRS requirements to be claimed as qualifying children or qualifying dependents. I understand that providing false information may result in penalties under federal law. I further acknowledge that this statement may be kept on file by the tax preparer as proof of authorization.
Parent/Guardian Phone Number:
Parent/Guardian Address:
SIGNATURES
Parent/Legal Guardian Signature:
Date:
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Month
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Day
Year
Date
Taxpayer Signature:
Date:
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Month
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Day
Year
Date
Witness/Preparer Signature (Optional):
Date:
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Month
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Day
Year
Date
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