Form 482.0 R - Individual Income Tax Return - 2001 Page 6

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Schedule CH Individual
RELEASE OF CLAIM TO EXEMPTION
Rev. 05.01
FOR CHILD (CHILDREN) OF DIVORCED
200__
OR SEPARATED PARENTS
Taxable year beginning on ____________, ____ and ending on ___________, ____
Name of parent claiming the exemption
Social Security Number
Part I
Release of Claim to Exemption for Dependents for Current Year
(See instructions)
I, ______________________________________________ , agree and compromise not to claim an exemption for dependents for
Name of parent releasing claim exemption
the taxable year 200__ for (enter the name(s) of child(children)):
(1)___________________________________________________________________
(2)___________________________________________________________________
(3)___________________________________________________________________
(4)___________________________________________________________________
(5)___________________________________________________________________
____________________________________________
_________________________
________________
Signature of parent releasing claim exemption
Social Security Number
Date
If you choose not to claim an exemption for this(these) child(children) for future taxable years, complete Part II.
Part II
Release of Claim to Exemption for Dependents for Future Years
(See instructions)
I, ______________________________________________ , agree and compromise not to claim an exemption for dependents for
Name of parent releasing claim exemption
the taxable year(s)_______________________ for (enter the name(s) of child(children)):
(Specify)
(1)___________________________________________________________________
(2)___________________________________________________________________
(3)___________________________________________________________________
(4)___________________________________________________________________
(5)___________________________________________________________________
____________________________________________
_________________________
________________
Signature of parent releasing claim exemption
Social Security Number
Date

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