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 Foot & Tick, CPAs" to submit this one, then press "Clear Form", enter your next dependent information and press "Send to Foot & Tick, CPAs" again
...repeat for additional dependents.