613 N Walnut Ave, Suite A
Broken Arrow, OK 74012
Taxpayers Signature Date Signed
EIC Questionnaire and Information Authorization Form
Interviewer ______________________ Date_________________________
IRS requires preparers to ask questions to help verify that taxpayers are eligible to receive EIC and intends to subject preparers
to large penalties for failing to ask what IRS deems sufficient questions to verify eligibility.
That is why we must complete this questionnaire for your return, and keep it in our records.
This questionnaire accompanies your information given in connection with your return, including all the dependents you list.
Taxpayer’s Name(s) _____________________________________________ Number of Dependents ___________
Taxpayer’s Address ____________________________________________________________________________
Did you live at this address for all of Year? ____________ If no, other Address __________________________________
Dependent Names, DOB _____________________________________________________________________________
School(s) Dependents Attended __________________________________________________________Documents?____
Child’s Doctor or Daycare _____________________________________________________________ Documents?_____
Source of Income _____________________________________ Total Income for Year _________________________
Do you have a business? _____________________________ Do you have documents to prove your income? ___________
Did anyone else contribute more than 50% of the cost to support your dependents? _______________________________
Did any of your dependents live with you for less than 12 months? ___________________ If so, explain on separate sheet
Were you married on December 31? _______________ Do any other adults live with you? ____________________
If other adults live with you, how much did they pay for household expenses (Rent, Food, Utilities) ____________________
Name of other Adult living with you and their total income for year ____________________________________________
Did you receive any financial assistance for your child? Circle any that apply Child Support SSI Welfare Housing WIC
Can anyone else claim your dependent on their tax return? Yes No
If you have a disabled dependent, do you have documentation? ________________________________
To facilitate the answering of any question pursuant to the preparation of my tax return, or any follow up required, I hereby
give my full consent that any medical or school provider for myself or my children or dependents release such information as
may be needed to further prove their dependency status to Matt McLean Tax Services, LLC. Under penalties of perjury, I
have answered the above questions correctly to the best of my knowledge.