Dependent Name:          Social Security No:

Birthdate (MO/DA/YR)       Relationship:       Months in Household:

Dependent's Gross Income

Is this dependent a U.S. Citizen? Yes / No

Was this dependent a full time student during the tax year? Yes / No

Did this dependent have unearned income greater than $3,400? No / Yes

If yes, enter source(s), type, and amount of such income

NOTE: If you have other dependents: Press "Send to Jack Burson, CPA" to submit this one, then press "Clear Form", enter your next dependent information and press "Send to Jack Burson, CPA" again
...repeat for additional dependents.