Head Of Household Schedule (Ftb 4803e) - 2014 (Page 2 of 2) in pdf

Hospital or convalescence

Birth or death

College

Lived with other parent

Moved in or out

Other (please explain)

Code

If your qualifying person was a foster child, was the child placed with you by an authorized placement

agency or by a judgment, decree, or other order of a court?

Yes

If Yes, what is the name of the placement agency or court that ordered the placement?

_______________________________________________________________________________

Was your qualifying person married or an RDP as of December 31, 2014?

Yes

If Yes, did this person file a joint federal or state tax return for 2014 with his or her spouse or RDP?

Yes

10. Was your qualifying person a citizen of the U.S. or a resident of the U.S., Canada, or Mexico?

Yes

11a. Were you married or an RDP as of 12/31/2014?

Yes

You were married or an RDP unless one of the following applied:

 You never married and never entered into a registered domestic partnership.

 You received a final decree of divorce, legal separation, or dissolution of registered domestic partnership by

12/31/2014, or you filed a Notice of Termination of Domestic Partnership with the Secretary of State that

was effective by 12/31/2014.

 Your marriage or registered domestic partnership was annulled.

 Your spouse/RDP died before 01/01/2014.

If none of the above circumstances applied to you as of the last day of the year, select Yes.

A petition for divorce, legal separation, or dissolution of registered domestic partnership is not the same as a

final decree. You remain married or an RDP until a final decree is issued or, if you filed a Notice of

Termination, until the six-month waiting period for the notice to become final has passed.

11b. Did you live with your spouse/RDP at any time during 2014?

Yes

If yes, list the beginning and ending dates for each period when you lived together:

(MM/DD/YY) From: ___________ To: ______________ From: ___________ To: ______________

Please provide a telephone number and the best time we can reach you between 7 a.m. and 5 p.m. weekdays, except state

holidays, in case we need more information.

Telephone number: (______) ___-____-____

Best time to call: _______________________

(Area code) (Number) (Extension)

FTB 4803e (REV 07-2014)

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Head Of Household Schedule (Ftb 4803e) - 2014 Page 2