EIC DUE DILIGENCE FOR HEAD OF HOUSEHOLD Name (first and last): Marital status: Select all that applyNever marriedSpouse deceasedDivorced or separatedMarried but lived apart from spouse during last 6 months of the yearSeparation agreement*please use ctrl key to select multiple itemsIf you are divorced or legally separated, could you provide the IRS with any of the following documents if requested:Divorce Decree Yes No Separate maintenance agreement or separation agreement Yes No If you are married but did not reside with your spouse for the last 6 months of the year, could you if requested provide the IRS with any of the supporting documents verifying that your spouse did not live with you? Select all that apply:Not applicableLease agreementUtility billsLetter from social servicesOther supporting documentation. Please describe below:*please use ctrl key to select multiple itemsDescribe other supporting documentation: If requested could you provide the IRS with receipts and bills substantiating the cost of maintaining more than half of the cost of the home? Documentation the IRS requires to substantiate the cost of maintaining the home could include any of the following. Select all that apply:Utility billsProperty tax billsGrocery receiptsRent receipts or mortgage interest statementOther household bills*please use ctrl key to select multiple itemsDid you receive any non-taxable support/income? Select all that apply:Family supportFood stampsHousing assistanceChildcare assistanceOther.*please use ctrl key to select multiple itemsDescribe other non-taxable support/income: By checking this box and leaving the last 4 digits of my social security number I verify the information I have provided above is honest and factual to the best of my knowledge.** Confirm The last 4 digits of my social security number are:* CAPTCHA
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