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FORM 2120, PAGE 1 of 2 (PAGE 2 IS BLANK)1 2 PRINTS: FACE ONLY O.K. to print
MARGINS: TOP 13mm ( ⁄ "), CENTER SIDES.
PAPER: WHITE WRITING, SUB. 20. INK: BLACK
FLAT SIZE: 203mm (8") 279mm (11")
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Form 2120 OMB No. 1545-0074
(Rev. October 2005) Multiple Support Declaration
Department of the Treasury Attachment
Internal Revenue Service Attach to Form 1040 or Form 1040A. Sequence No. 114
Name(s) shown on return Your social security number
During the calendar year , the eligible persons listed below each paid over 10% of the support of:
Name of your qualifying relative
I have a signed statement from each eligible person waiving his or her right to claim this person as a dependent for any tax year
that began in the above calendar year.
Eligible person’s name Social security number
Address (number, street, apt. no., city, state, and ZIP code)
Eligible person’s name Social security number
Address (number, street, apt. no., city, state, and ZIP code)
Eligible person’s name Social security number
Address (number, street, apt. no., city, state, and ZIP code)
Eligible person’s name Social security number
Address (number, street, apt. no., city, state, and ZIP code)
Note. To find out what is included in support, see Pub. 501,
Instructions Exemptions, Standard Deduction, and Filing Information.
What’s New Signed Statement
The rules for multiple support agreements still apply to claiming an You must have received, from each other eligible person listed
exemption for a qualifying relative, but they no longer apply to above, a signed statement waiving his or her right to claim the
claiming an exemption for a qualifying child. For the definitions of person as a dependent for the calendar year indicated on this form.
“qualifying relative” and “qualifying child,” see your tax return The statement must include:
instruction booklet.
● The calendar year the waiver applies to,
Purpose of Form ● The name of your qualifying relative the eligible person helped to
Use Form 2120 to: support, and
● Identify each other eligible person (see below) who paid over 10% ● The eligible person’s name, address, and social security number.
of the support of your qualifying relative whom you are claiming as a Do not file the signed statement with your return. But you must keep
dependent, and it for your records and be prepared to furnish it and any other
● Indicate that you have a signed statement from each other eligible information necessary to show that you qualify to claim the person
person waiving his or her right to claim that person as a dependent. as your dependent.
An eligible person is someone who could have claimed a person
as a dependent except that he or she did not pay over half of that Additional Information
person’s support. See Pub. 501 for details.
If there are more than four other eligible persons, attach a
statement to your return with the required information. Paperwork Reduction Act Notice. We ask for the information on this
form to carry out the Internal Revenue laws of the United States. You are
Claiming a Qualifying Relative required to give us the information. We need it to ensure that you are
Generally, to claim a person as a qualifying relative, you must pay complying with these laws and to allow us to figure and collect the right
over half of that person’s support. However, even if you did not meet amount of tax.
this support test, you may be able to claim him or her as a You are not required to provide the information requested on a form
dependent if all five of the following apply. that is subject to the Paperwork Reduction Act unless the form displays a
valid OMB control number. Books or records relating to a form or its
1. You and one or more other eligible person(s) (see above) instructions must be retained as long as their contents may become
together paid over half of that person’s support. material in the administration of any Internal Revenue law. Generally, tax
2. You paid over 10% of the support. returns and return information are confidential, as required by Internal
Revenue Code section 6103.
3. No one alone paid over half of that person’s support. The average time and expenses required to complete and file this form
4. The other dependency tests are met. See Step 4, Is Your will vary depending on individual circumstances. For the estimated
Qualifying Relative Your Dependent? in the Form 1040 or Form averages, see the instructions for your income tax return.
1040A instructions. If you have suggestions for making this form simpler, we would be
5. Each other eligible person who paid over 10% of the support happy to hear from you. See the instructions for your income tax return.
agrees not to claim that person as a dependent by giving you a
signed statement. See Signed Statement on this page.
Cat. No. 11712F Form 2120 (Rev. 10-2005)