8915 Qualified Hurricane Retirement Plan Distributions and Re

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Form

2120

Department of the Treasury
Internal Revenue Service

Name(s) shown on return

During the calendar year

OMB No. 1545-0071

Multiple Support Declaration

(Rev. December 2005)

䊳

Attachment
Sequence No.

Attach to Form 1040 or Form 1040A.

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Your social security number

, 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

Signed Statement

What’s New
The rules for multiple support agreements still apply to claiming an
exemption for a qualifying relative, but they no longer apply to
claiming an exemption for a qualifying child. For the definitions of
“qualifying relative” and “qualifying child,” see Pub. 501, Exemptions,
Standard Deduction, and Filing Information.

Purpose of Form
Use Form 2120 to:
● Identify each other eligible person (see below) who paid over 10%
of the support of your qualifying relative whom you are claiming as a
dependent, and
● Indicate that you have a signed statement from each other eligible
person waiving his or her right to claim that person as a 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
person’s support.
If there are more than four other eligible persons, attach a
statement to your return with the required information.

Claiming a Qualifying Relative
Generally, to claim a person as a qualifying relative, you must pay
over half of that person’s support. However, even if you did not meet
this support test, you may be able to claim him or her as a
dependent if all five of the following apply.
1. You and one or more other eligible person(s) (see above)
together paid over half of that person’s support.
2. You paid over 10% of the support.
3. No one alone paid over half of that person’s support.
4. The other dependency tests are met. See Step 4, Qualifying
Relative Dependent in the Form 1040 or Form 1040A instructions.
5. Each other eligible person who paid over 10% of the support
agrees not to claim that person as a dependent by giving you a
signed statement. See Signed Statement on this page.

You must have received, from each other eligible person listed
above, a signed statement waiving his or her right to claim the
person as a dependent for the calendar year indicated on this form.
The statement must include:
● The calendar year the waiver applies to,
● The name of your qualifying relative the eligible person helped to
support, and
● The eligible person’s name, address, and social security number.
Do not file the signed statement with your return. But you must keep
it for your records and be prepared to furnish it and any other
information necessary to show that you qualify to claim the person
as your dependent.

Additional Information
See Pub. 501 for details.
Paperwork Reduction Act Notice. We ask for the information on this form to
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of any Internal Revenue law. Generally, tax returns and return information are
confidential, as required by Internal Revenue Code section 6103.
The time needed to complete and file this form will vary depending on
individual circumstances. The estimated average time is: Recordkeeping, 6
minutes; Learning about the law or the form, 4 minutes; Preparing the
form, 7 minutes; and Copying, assembling, and sending the form to the
IRS, 13 minutes.
If you have comments concerning the accuracy of these time estimates or
suggestions for making this form simpler, we would be happy to hear from
you. See the Instructions for Form 1040 or Form 1040A.

Cat. No. 11712F

Form

2120

(Rev. 12-2005)