8836 Form – Fill Out and Use This PDF

Taxpayer Information Your first name and initial Last name Your social security number.

Enter your box number only if your post office does not deliver mail to your home. Otherwise, enter your home street address.

Providing your daytime and evening phone numbers may help speed the processing of this form.

You may list a mobile phone number as your daytime or evening phone number (or both).

If you are filing a joint return for 2004, spouse's first name and initial Spouse's social security number.

If you and your spouse are filing a joint return, you only need to show that your child lived with one of you for more than half of 2004.

Enter each child's first and last name exactly as it appears on the child's social security card.

Your qualifying child must have a valid social security number (SSN), unless the child was born and died in 2004.

If the qualifying child was born and died in 2004 and did not have an SSN, attach a copy of that child's birth certificate to Form 8836 and enter “Died” instead of the child's SSN.

Be sure that any child named on this form is your qualifying child and you are listing or expect to list that child on Schedule EIC of your 2004 tax return.

Proof of Residency (see instructions). Check one or more boxes in Part III and attach any required documents. The documents must include your name, the child's name, street address, and dates the child lived with you. When taken together, the documents must show that you and the child lived together for more than half of 2004. See Residency Test on page 2 for details and exceptions. For details on who can provide documents, see page 3.

One or more third parties have completed the Third Party Affidavit, which I have attached. If the affidavit(s) shows that the residency test has been met, do not check any other boxes or attach additional information.

You can submit a Third Party Affidavit from any third party eligible to complete it.

Use only the version of the affidavit (schedule) you received with Form 8836.

I have attached copies of one or more of the following records (see page 3 to find out which records to send and the information these records must contain): Childcare records, Community-based organization records, Court or placement agency records, Employment records, Indian tribal records, Law enforcement reports, Legal records, Leases, Medical records, Religious records, School records, Social service agency records, Utility bills.

I have attached a signed letter on official letterhead from one or more of the following third parties (see page 3 for details on the information the letter must contain): Attorney, Childcare provider, Clergy, Community-based organization official, Court or placement agency official, Employer, Health-care provider, Indian tribal official, Landlord or property manager, School official, Social service agency or other government official, Utility company, Law enforcement officer.

Attach documents if you and your child were temporarily living apart due to special circumstances and you need to count the temporary absences to prove that your child met the residency test.

You can submit any combination of the documents listed as long as they show, when taken together, that your child lived with you for more than half of 2004.

In some cases, a single document will show that you and your child lived at the same address. In other cases, you may need to provide one document showing your name and address as well as a second document showing your child's name with the same address.

You may need more than one document to show that your address and your child's address were the same for more than half of 2004.

You must sign and date Part III under penalties of perjury before you send it to the IRS with the documents.

You cannot file your tax return by fax. You can file Form 8836 either before January 1, 2005, or after December 31, 2004, but no later than the date you file your 2004 tax return.

Send Form 8836 to: Internal Revenue Service, Stop 4300, Annex R2, Kansas City, MO 64999-0065. After December 31, 2004, you can file it at that address. You can also file Form 8836 and any supporting documents by fax at 1-913-266-9640 (not a toll-free number).

Criminal penalties may be imposed for making a false statement.

Under penalties of perjury, I declare that I have examined this statement, and to the best of my knowledge and belief, it is true, correct, and complete.

Do not file Form 8836 if your child does not meet the residency test for 2004, because the IRS will not allow the EIC based on a qualifying child.