Schedule A1 Individual - Dependents And Beneficiaries Of Educational Contribution Accounts - 2009

Schedule A1 Individual

DEPENDENTS AND BENEFICIARIES

Rev. 01.10

2009

OF EDUCATIONAL CONTRIBUTION ACCOUNTS

Taxable year beginning on _________________, _____ and ending on ________________, _____

Taxpayer’s name

Social Security Number

Part I

Dependent’s Information

(See instructions)

55

IMPORTANT INFORMATION PART I

Do not include the spouse on this schedule. A married individual who lives with his spouse is not a head of household for tax purposes, therefore, you should not include

the wife’s name in the box for head of household (line 01).

If you claim the head of household filing status, include the dependent who entitles you to claim such status on the Head of Household line (01), but do not

claim the exemption for this dependent.

In order to consider the exemption for dependents you must include this Schedule with your return.

First Name, Initial

Last Name

Second Last Name

Head of Household

Category

Date of Birth

Social Security Number

R e l a t i o n s h i p

(01)

J

NOT THE TAXPAYER / NOT THE SPOUSE

Relationship

First Name, Initial

Last

Second Last

Category

Date of Birth

Social Security Number

*

(N) (U) (I)

Name

Name

Day / Month / Year

(02)

(03)

(04)

(05)

(06)

(07)

(08)

(09)

(10)

Part II

Beneficiaries of Educational Contribution Accounts

(See instructions)

57

IMPORTANT INFORMATION PART II

These beneficiaries must not be considered to determine the exemption for dependents. However, if any of these beneficiaries qualifies as your dependent, you must also

include him/her in Part I of this Schedule.

Contributed Amount

(01)

Name, Initial

Last Name

Second Last Name

Date of Birth (Day/Month/Year)

Relationship

*

Social Security Number

(Not to exceed from $500 each)

Financial Institution

Account Number

Employer Identification Number

00

Name, Initial

Last Name

Second Last Name

*

Date of Birth (Day/Month/Year)

Social Security Number

Contributed Amount

(02)

Relationship

(Not to exceed from $500 each)

Account Number

Financial Institution

Employer Identification Number

00

Social Security Number

Relationship

*

Contributed Amount

(03)

Name, Initial

Last Name

Second Last Name

Date of Birth (Day/Month/Year)

(Not to exceed from $500 each)

Financial Institution

Account Number

Employer Identification Number

00

(10)

Total contributions (Add lines (01) through (03) and transfer to Schedule A Individual, Part II, line 8 or to Schedule CO Individual,

line 10H, as applicable) ..............................................................................................................................................................

00

*See instructions.

Retention Period: Ten (10) years