7

TLS, have you I.R.S. SPECIFICATIONS TO BE REMOVED BEFORE PRINTING

transmitted all R Action Date Signature
text files for this INSTRUCTIONS TO PRINTERS
cycle update? FORM 8836, PAGE 1 OF 4
MARGINS; TOP 13mm (1⁄2 "), CENTER SIDES. PRINTS: HEAD TO HEAD O.K. to print
PAPER: WHITE WRITING, SUB. 20. INK: BLACK
FLAT SIZE: 11"x17"; FOLD TO 216mm (81⁄2 ") x 279mm (11")
Date PERFORATE: ON FOLD Revised proofs
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT requested

Qualifying Children Residency Statement

Form 8836 (for the earned income credit)
OMB No. 1545-0074

2005
䊳 Esta forma está disponible en español. Por favor, llame al 1-800-829-6088.
Department of the Treasury Attachment
Internal Revenue Service 䊳 See instructions beginning on page 2. Sequence No. 136
Part I Taxpayer Information
Your first name and initial Last name Your social security number

If you are filing a joint return for 2005, spouse’s first name Last name Spouse’s social security number
and initial

Home address (number and street). If you have a P.O. box, see instructions Your daytime phone number
( )
City, town or post office, state, and ZIP code Your evening phone number
( )
Part II Qualifying Children Information
Caution. Enter each child’s first and last name exactly as it appears on the child’s social security card.

Child 1 䊳 Child’s first name Last name Child’s social security number

Child 2 䊳
Child’s first name Last name Child’s social security number

Part III Proof of Residency (see instructions)

You must prove your child lived with you for more than half of 2005. For details and exceptions, see Residency Test on
page 2.
The proof you must give us is a Third Party Affidavit or other document(s) showing the child lived with you for more than
half of 2005. For details on the documents to provide, what the documents must show, and who can provide documents,
see page 3. Note. The IRS may contact any person or organization that provides documents you attach to this form.
Check one or more boxes below and attach the required documents.

1 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.
Note. The Third Party Affidavit was sent to you with Form 8836 and is designated either Schedule A (Form 8836) or
Schedule B (Form 8836). Use only the version of the schedule you received with Form 8836.

2 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 Employer School official
Childcare provider Health-care provider Social service agency or
Clergy Indian tribal official other government official
Community-based organization official Landlord or property manager Utility company
Court or placement agency official Law enforcement officer

3 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 Law enforcement reports Religious records
Community-based organization records Leases School records
Court or placement agency records Legal records Social service agency records
Employment records Medical records Utility bills
Indian tribal records

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
Keep a complete.
copy of

䊳
Form 8836 Taxpayer
and
Sign Here Date 䊳
attachments
for your
records.
Spouse Named in
Part I Sign Here 䊳 Date 䊳

For Privacy Act and Paperwork Reduction Act Notice, see page 4. Cat. No. 14955C Form 8836 (2005)
 7
I.R.S. SPECIFICATIONS TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM 8836, PAGE 2 OF 4
MARGINS; TOP 13mm (1⁄2 "), CENTER SIDES. PRINTS: HEAD TO HEAD
PAPER: WHITE WRITING, SUB. 20. INK: BLACK
FLAT SIZE: 216mm (8 ⁄2 ") x 279mm (11")
1

PERFORATE:
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Form 8836 (2005) Page 2

How To Get Help

Call 1-800-829-6088 if you need help completing this form or you cannot get the documents you need to send
with this form. Help is available Monday through Friday from 8:00 a.m. to 8:00 p.m. local time.
You may also visit any IRS Taxpayer Assistance Center. To find out the location and hours of the nearest
center, call 1-800-829-1040 or visit the IRS website at www.irs.gov/localcontacts. You also can contact the
Taxpayer Advocate Service at 1-877-777-4778 or the local Taxpayer Advocate office in your area.
After you file this form, you can find out whether we received and approved it. Go to www.irs.gov/eitc and
click on the link for the EITC Certification Application, or you can call 1-800-829-6088. Allow at least 30 days
after filing the form before you do this. You will need information from your last tax return to access this
information.

Instructions Where To File

Purpose of Form Send Form 8836 to:
We need this form to show that your child met the residency Internal Revenue Service
test (defined on this page) for the earned income credit (EIC) EITC Operations, Stop 4300, Annex R2
for 2005. Kansas City, MO 64999-0065
After December 31, 2005, you can either file it at the
Who Must File above address or attach it to your tax return. If you file it with
your return, send it to:
File this form only if:
● The IRS sent this form to you with a letter directing you to Internal Revenue Service Center
file it, and Kansas City, MO 64999-0002
● You are claiming or expect to claim the EIC with a
Do not send your tax return to the address listed
qualifying child for 2005. A qualifying child is one who meets
in your tax return instructions if that address is
the age, relationship, and residency tests for the EIC.
CAUTION
different from the address just given.
The relationship test has changed for 2005. To
File Form 8836 by fax. You can also file Form 8836 and any
meet the relationship test, the child must be your
supporting documents by fax at 1-913-266-9640 (not a
child (including an adopted child, stepchild, or
CAUTION toll-free number). You cannot file your tax return by fax.
eligible foster child), brother, sister, stepbrother,
stepsister, or a descendant of one of these relatives. An Electronic Filers
adopted child includes a child lawfully placed with you for
legal adoption. An eligible foster child is any child who is You cannot file Form 8836 electronically. However, you may
placed with you by an authorized placement agency or by still file your tax return electronically. If you do so, send Form
judgment, decree, or other order of any court of competent 8836 and all required attachments to:
jurisdiction. Internal Revenue Service
EITC Operations, Stop 4300, Annex R2
If you are required to, but do not file Form 8836, the IRS
Kansas City, MO 64999-0065
will not allow the EIC with a qualifying child for 2005. If the
IRS does not allow your EIC, we will notify you of your Residency Test
appeal rights.
Your child must have lived with you in the United States for
Do not file Form 8836 if your child does not meet the more than half of 2005 (at least 183 days). Include any time
residency test for 2005, because we will not allow the EIC that you and your child were temporarily living apart due to
based on a qualifying child. special circumstances, such as military service, school
For details on the EIC eligibility rules, see Pub. 596, attendance, hospitalization, or juvenile detention. It does not
Earned Income Credit (EIC). You can order Pub. 596 by matter where you lived with your child. For example, you
calling 1-800-TAX-FORM (1-800-829-3676) or you can may live with your child in a homeless shelter. For more
download it from the IRS website at www.irs.gov. You can details on the residency test, see Pub. 596.
also use the EITC Assistant at www.irs.gov/eitc to find out if
you are eligible for EIC. Special rule for a child who was born or died in 2005. A
child is considered to have lived with you for more than half
Pre-recorded information about the EIC is also available by of 2005 if the child was born or died in 2005 and your home
phone 24 hours a day, 7 days a week. Call 1-800-829-4477 was the child’s home for the entire time he or she was alive
and select TeleTax topic No. 601. Have paper and a pen or in 2005.
pencil handy to take notes.
What We Will Do After We Receive This
When To File Form
There are two different time periods for filing Form 8836 for We will review the information you send us. We will send you
2005. You can file Form 8836 either: a letter to let you know if your child has met the residency
● Before January 1, 2006. If you file the form during this test. If we need more information, we will contact you.
period, you may be able to avoid a delay in receiving the EIC If one or more of your children do not meet the residency
part of your tax refund for 2005. test, we will send you a letter to let you know. The IRS will
● After December 31, 2005, but no later than the date you not allow the EIC based on that child. If you have other
file your 2005 tax return. Under this option, the EIC part of children for whom you can provide documents, you will have
your refund will be delayed while we review the information the opportunity to do so. If the IRS does not allow all of your
you submitted. EIC, we will notify you of your appeal rights.
 7
I.R.S. SPECIFICATIONS TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM 8836, PAGE 3 OF 4
MARGINS; TOP 13mm (1⁄2 "), CENTER SIDES. PRINTS: HEAD TO HEAD
PAPER: WHITE WRITING, SUB. 20. INK: BLACK
FLAT SIZE: 216mm (81⁄2 ") x 279mm (11")
PERFORATE:
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Form 8836 (2005) Page 3

If you move after you file Form 8836, notify us in writing of military orders showing the dates you were away and where
your new address. To do this, use Form 8822, Change of you were stationed.
Address.
For more information, see How to Get Help, at the top of If you cannot obtain a completed Third Party Affidavit,
page 2. records, or a signed letter from one or more third parties
to show that your child lived with you for more than half
Part I of 2005, call 1-800-829-6088 and we will help you.
P.O. Box. Enter your box number only if your post office What the documents must show. If you send an official
does not deliver mail to your home. Otherwise, enter your record or letter, it must clearly show:
home street address.
● Your name, your child’s name, or both names,
Daytime and evening phone numbers. Providing your
daytime and evening phone numbers may help speed the ● A street address and the dates that you or your child lived
processing of this form. We may have questions about the at that address during 2005, and
information you provided. If you answer our questions over ● The name, address, and phone number of the person or
the phone, we may be able to continue processing the form organization that provided the record or letter.
without mailing you a letter. You may list a mobile phone Who can provide documents to you. You can submit a
number as your daytime or evening phone number (or both). Third Party Affidavit from any third party eligible to complete
If you will be filing a joint return, you may enter either it. You can submit copies of records or signed letters on
spouse’s phone numbers. official letterhead from any of the following third parties (other
than you, your spouse, your dependent, your qualifying child
Part II for the earned income credit, or a parent of that qualifying
Be sure that any child named on this form is your qualifying child).
child and you are listing or expect to list that child on ● School official (such as a teacher, principal, or
Schedule EIC of your 2005 tax return. administrative assistant). A school includes Head Start, pre-K
Your qualifying child must have a valid social security programs, and before or after school care provided by a
number (SSN), unless the child was born and died in 2005. If school.
the qualifying child was born and died in 2005 and did not ● Health-care provider (such as your doctor, your nurse
have an SSN, attach a copy of that child’s birth certificate to practitioner, or a clinic official).
Form 8836 and enter “Died” instead of the child’s SSN. ● Member of the clergy (such as your minister, priest, rabbi,
For EIC purposes, a valid SSN is a number issued by the or imam).
Social Security Administration unless “Not Valid for ● Childcare provider who is age 18 or older (such as a
Employment” is printed on the social security card and the babysitter or daycare provider).
number was issued solely to receive a federally funded
● Your employer (such as a personnel official, supervisor, or
benefit.
work leader).
We will not allow the EIC based on a qualifying child who
● Landlord or property manager (including a building
has, instead of an SSN:
superintendent, public housing official, or rental agent).
● An individual taxpayer identification number (ITIN), which
● Social service agency or other government official (such as
the IRS issues to noncitizens who cannot get an SSN, or
a social worker, case worker at a public assistance office, or
● An adoption taxpayer identification number (ATIN), which operator of a homeless shelter).
the IRS issues to adopting parents who cannot get an SSN
● Community-based organization official (such as an official
for the child being adopted until the adoption is final.
from the YMCA, YWCA, Boy Scouts, Girl Scouts, Boys and
Part III Girls Clubs, 4-H, Little League, Police Athletic League,
immigrant advocacy groups, neighborhood associations,
You must attach a Third Party Affidavit or other documents homeowners and condominium associations, and other
showing that each qualifying child listed on Schedule EIC nonprofit groups).
lived with you for more than half of 2005. You may need to
send more than one affidavit or other document to show that ● Indian tribal official.
your child lived with you for more than half of 2005. ● Attorney who handled your divorce or child custody case.
If you and your spouse are filing a joint return, you only ● Official of the court or agency that issued a decision or
need to show that your child lived with one of you for more order involving your divorce or custody, support, or
than half of 2005. placement of your child.
What kind of documents you must provide. You may ● Law enforcement officer (such as a police officer or parole
provide any of the following: officer).
● The Third Party Affidavit. Use only the version of the ● Utility company (such as an electric or gas company).
affidavit (schedule) you received with Form 8836. Keep a How many documents do you need? You can submit any
copy for your records. combination of the documents listed on this page as long as
● A signed letter on official letterhead. Keep a copy for your they show, when taken together, that your child lived with
records. you for more than half of 2005. In some cases, a single
● A copy of a record (such as school records, medical document will show that you and your child lived at the same
records, childcare records, a lease, or a pay stub). Do not address. In other cases, you may need to provide one
send any original records. document showing your name and address as well as a
second document showing your child’s name with the same
Temporary absences. Attach documents if you and your address. You may need more than one document to show
child were temporarily living apart due to special that your address and your child’s address were the same
circumstances and you need to count the temporary for more than half of 2005.
absences to prove that your child met the residency test.
See Residency Test on page 2. For example, if you were Here are examples of acceptable document combinations:
away from home on military duty, attach a copy of your ● One document that shows that both you and your child
lived at the same address for more than half of 2005.
 7
I.R.S. SPECIFICATIONS TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM 8836, PAGE 4 OF 4
MARGINS; TOP 13mm (1⁄2 "), CENTER SIDES. PRINTS: HEAD TO HEAD
PAPER: WHITE WRITING, SUB. 20. INK: BLACK
FLAT SIZE: 216mm (81⁄2 ") x 279mm (11")
PERFORATE: None
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Form 8836 (2005) Page 4

● One document that shows that you lived at an address for Privacy Act and Paperwork Reduction Act Notice. The
more than half of 2005 and a second document that shows Privacy Act of 1974 and the Paperwork Reduction Act of
that your child lived at the same address during the same 1980 require that when we ask you for information we must
period of time. first tell you our legal right to ask for the information, why we
● One document that shows that you and your child lived at are asking for it, and how it will be used. We must also tell
the same address for part of 2005 and a second document you what could happen if we do not receive it and whether
that shows that you and your child lived together for the rest your response is voluntary, required to obtain a benefit, or
of 2005. mandatory under the law.
● If you have two children, separate documents for each This notice applies to all papers you file with us. It also
child to show that each one lived with you for more than half applies to any questions we need to ask you so we can
of 2005. complete, correct, or process your return; figure your tax;
and collect tax, interest, or penalties.
● If you have two children, one document to show that both
of your children lived with you for more than half of 2005. Our legal right to ask for information is Internal Revenue
Code sections 6001, 6011, and 6012(a), and their regulations.
Example 1. You attach a letter on official letterhead from They say that you must file a return or statement with us for
Acme Medical Clinic showing that your child lived with you any tax for which you are liable. Your response is mandatory
from January 1, 2005, through March 31, 2005. You also under these sections. Code section 6109 and its regulations
have Reverend Smith, your clergyman, complete a Third say that you must provide your taxpayer identification
Party Affidavit showing that you and your child lived together number on what you file. This is so we know who you are,
from April 1, 2005, through July 31, 2005. You check the first and can process your return and other papers.
and second boxes in Part III. Because the total time shown is
more than half of the year, the residency test is met. You are not required to provide the information requested
on a form that is subject to the Paperwork Reduction Act
Example 2. You attach a transcript of your child’s grades unless the form displays a valid OMB control number. Books
from the Washington Elementary School showing that your or records relating to a form or its instructions must be
child lived with you from January 1, 2005, through May 31, retained as long as their contents may become material in
2005. You also attach a letter on official letterhead from the the administration of any Internal Revenue law. Generally, tax
principal of the Lincoln Middle School. The letter shows the returns and return information are confidential, as stated in
dates of school attendance and that the child’s address was Code section 6103.
the same as yours. The letter covers the period from
September 1, 2005, through December 31, 2005. You check We ask for tax return information to carry out the tax laws
the second and third boxes in Part III. Because the total time of the United States. We need it to figure and collect the
shown is more than half of the year, the residency test is right amount of tax.
met. We may give the information to the Department of Justice
Example 3. You attach seven electric bills from the Edison and to the other federal agencies, as provided by law. We
Electric Company for the months of January through May, may give it to cities, states, the District of Columbia, and
September, and October of 2005 showing your name and U.S. commonwealths or possessions to carry out their tax
address on them. You also attach transcripts of your child’s laws. We may also disclose this information to other
grades from the Roosevelt Grade School showing your countries under a tax treaty, or to federal and state agencies
child’s name and the same address shown on your electric to enforce federal nontax criminal laws and to combat
bills. The transcripts cover the periods January through May terrorism.
2005 and September through November 2005. You If you do not file a return or give fraudulent information,
check the third box in Part III. Because you have shown that you may be charged penalties and be subject to criminal
the total time you and your child lived together was more prosecution.
than half the year, the residency test is met. Please keep this notice with your records. It may help you
Signing the form. You must sign and date Part III under if we ask you for other information. If you have any questions
penalties of perjury before you send it to us with the about the rules for filing and giving information, please call or
documents. Criminal penalties may be imposed for making a visit any Internal Revenue Service office.
false statement. The average time and expenses required to complete
and file this form will vary depending on individual
circumstances. For the estimated averages, see the
instructions for your income tax return.
If you have suggestions for making this form simpler, we
would be happy to hear from you. You can write to the
Internal Revenue Service, Tax Products Coordinating
Committee, SE:W:CAR:MP:T:T:SP, 1111 Constitution Ave.
NW, IR-6406, Washington, DC 20224. Do not send the form
to this address. Instead, see Where To File on page 2.