8840 Closer Connection Exception Statement for Aliens

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I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
SCHEDULE B (FORM 8836), PAGE 1 OF 2
MARGINS; TOP 13mm (1⁄2 "), CENTER SIDES.
PRINTS: HEAD TO HEAD
PAPER: WHITE WRITING, SUB. 20.
INK: BLACK
1
FLAT SIZE: 8 ⁄2 " x 11"
PERFORATE: NONE
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Date

SCHEDULE B
(Form 8836)

Date

䊳

Revised proofs
requested

OMB No. 1545-0074

2005

Esta forma está disponible en español. Por favor, llame al 1-800-829-6088.
䊳

Signature

O.K. to print

Third Party Affidavit

Department of the Treasury
Internal Revenue Service

Part I

Action

See instructions on back.

Taxpayer Information (to be completed by taxpayer)

Your first name and initial

Last name

Your social security number

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If you are filing a joint return for 2005, spouse’s first name
and initial

Last name

Affidavit (to be completed by third party only)

Part II

Note. The IRS may contact you to verify this affidavit.
1

You must check one box, and only one box, below that best describes your relationship to the taxpayer. See the instructions
to find out if you are eligible to complete Part II.
Attorney
Childcare provider
Clergy
Community-based organization official

Other (see instructions): (1) Relationship

2

Court or placement
agency official

Employer
Health-care provider
Indian tribal official

䊳

(2) How do you know child lived with taxpayer? 䊳
Child’s name. Enter the name of the child who lived with the taxpayer.
Child 1 (first and last name)

䊳

Note. If this affidavit covers only one child, check here
Child 2 (first and last name)
3

Landlord or property manager
Law enforcement officer
School official
Social service agency or other
government official

䊳

and do not enter a name on the line for Child 2 below.

䊳

Address. The child (or children) lived with a taxpayer (or both taxpayers) named in Part I at the following address. (If more
than one address applies, see the instructions.)
Address (number and street)
City, town or post office, state, and ZIP code

4

Start date. This affidavit covers the time period in 2005 during which the child (or children) lived with a taxpayer (or both
taxpayers) named in Part I. (If more than one period of time applies, see the instructions.)
Check the box that applies.
(1)
The child (or children) began living with the taxpayer before 2005.
(2)
The child (or children) began living with the taxpayer on
/
(month)

5

/2005.
(day)

End date. Check the box that applies.
(1)
The child (or children) has lived with the taxpayer at the above address since the start date.
(2)
The child (or children) lived with the taxpayer at the above address until
/
/2005.
(month)

(day)

Based on my records or personal knowledge, I certify that the child (or children) named in Part II lived with the taxpayer(s) named
in Part I at the address shown above during the period of time shown.
Under penalties of perjury, I declare that I have examined this affidavit, and to the best of my knowledge and belief, it is true, correct, and complete.

䊳

Third Party
Sign Here
Your name
(print or type)

䊳

Name of organization (if any)
Address (number and street)

Date

䊳

Title (if any)

䊳

䊳

City, town or post office, state, and ZIP code
Your daytime phone number
(

Best time to call

)

For Privacy Act and Paperwork Reduction Act Notice, see Form 8836.

Cat. No. 37452M

Schedule B (Form 8836) 2005

5
I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
SCHEDULE B (FORM 8836), PAGE 2 OF 2
MARGINS; TOP 13mm (1⁄2 "), CENTER SIDES.
PRINTS: HEAD TO HEAD
PAPER: WHITE WRITING, SUB. 20.
INK: BLACK
1
FLAT SIZE: 8 ⁄2 " x 11"
PERFORATE: NONE
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Schedule B (Form 8836) (2005)

Page

Instructions for Taxpayer
Purpose of Form
You may ask a third party to complete the affidavit on
Schedule B (Form 8836) to show that you and your
qualifying child lived together in the United States for part
or all of 2005. Attach Schedule B to Form 8836,
Qualifying Children Residency Statement. See Form 8836
for more details.

2

You may not complete the affidavit if you are the
taxpayer’s spouse, dependent, or qualifying child (for the
earned income credit), or you are a parent of that
qualifying child. Below are examples of the people who
are in the categories listed on the form.
● Attorney who handled the taxpayer’s divorce or child
custody case.
● Childcare provider if you are at least age 18 (such as a
babysitter or daycare provider).
● Member of the clergy (including a minister, priest, rabbi,
or imam).
● Community-based organization official (including an
official from the YMCA, YWCA, Boy Scouts, Girl Scouts,
Boys and Girls Clubs, 4-H, Little League, Police Athletic
League, immigrant advocacy groups, neighborhood
associations, homeowners and condominium
associations, and other nonprofit groups).
● Official of the court or agency that issued a decision or
order involving the taxpayer’s divorce or custody, support,
or placement of the taxpayer’s child.
● Employer (such as a personnel official, supervisor, or
work leader).
● Health-care provider (including a doctor, nurse
practitioner, or clinic official).
● Indian tribal official.
● Landlord or property manager (including a building
superintendent, public housing official, or rental agent).
● Law enforcement officer (such as a police officer or
parole officer).
● School official (including a teacher, principal, or
administrative assistant). A school includes Head Start,
pre-K programs, and before or after school care provided
by the school.
● Social service agency or other government official
(including a social worker, case worker at a public
assistance office, or operator of a homeless shelter).

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Who Is a Third Party?

A third party is anyone whose relationship to you or your
child is listed on page 1 of Schedule B and who has
records that show, or who personally knows, that you and
your qualifying child lived together for part or all of 2005.
A third party does not include you, your spouse, your
dependent, your qualifying child (for the earned income
credit), or a parent of that qualifying child.

How Many Schedules B Do You Need?

You may use as many Schedules B as you need (in
combination with copies of records and letters on official
letterhead), as long as they show, when taken together,
that your child lived with you for more than half of 2005.
Do not use Schedule B if the records or letters you are
submitting with Form 8836 already show your child lived
with you for more than half the year in 2005. Do not
attach Schedules B for children not listed on Form 8836.
If we decide that one or both of the children you list on
this schedule is not a qualifying child, we will contact you
and give you the opportunity to send us information about
another child. See Form 8836 for more details.

What Do You Need To Tell the Third Party?
Before giving Schedule B to the third party, complete
your name, and your spouse’s name (if you are filing a
joint return for 2005) at the top of the schedule. You must
also enter your social security number, but you can wait
until after the third party completes the affidavit.
Ask the third party to completely fill in all applicable
entry spaces on the affidavit and sign and date it. If you
have more than two children, and the third party has
information relating to more than two of your children, be
sure to tell the third party the names of the two qualifying
children you are claiming on Form 8836.
If the third party does not complete all applicable
information, the affidavit may not be accepted.

Instructions for Third Party
The taxpayer has given you this affidavit to verify the
period during 2005 that the taxpayer and one or two of
his or her children lived together in the United States. If
you fill out this affidavit, then you must complete all
applicable information on the affidavit based on your
records or personal knowledge and sign it under penalties
of perjury. After completing and signing the
affidavit, return it to the taxpayer. Do not send it to the
IRS. Criminal penalties may be imposed for knowingly
making a false statement.

● Other. This means anyone not listed above, such as a
friend or neighbor, who has personal knowledge that the
child (or children) named on the form lived with the
taxpayer for more than half the year. If this applies to you,
check the “Other” box in Part II and briefly describe your
relationship to the taxpayer and how you know the child
(or children) lived with the taxpayer. For example, after
“Relationship” enter “Neighbor,” and after “How do you
know child lived with taxpayer?” enter “I have lived next
door to David and his children for the past 5 years.”

More Than One Address or Period
If the taxpayer and child (or children) lived together at
more than one address or during two or more separate
periods during 2005, you must either:
● Complete a separate Schedule B for each address and
time period, or
● Enter “see attached” on line 3 and to the right of lines 4
and 5 and attach a separate statement (which can be
typed or written on a plain piece of paper) listing the
taxpayer’s name and addresses and time periods that the
taxpayer and child (or children) lived at each address. You
must also sign the attached statement.

Who Is Eligible To Complete Part II?

How To Get Help

You are eligible to complete Part II if you have records or
personal knowledge that the child (or children) named on
the form lived with the taxpayer more than half the year.

If you need assistance completing this schedule, call
1-800-829-6088. Assistance is available Monday
through Friday from 8:00 a.m. to 8:00 p.m. local time.