Form D-40 - Individual Income Tax Return - 2011 Page 11
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*110400160002*
Qualifying Child Information
First Name
M.I.
Last Name
1. Child’s name, #1
Child’s name, #2
Child’s name, #3
If you have more than three qualifying children, you only need to list three to get the maximum credit.
#1
#2
#3
2. Child’s
SSN
#1
#2
#3
3. Child’s date of birth
First Name
M.I.
Last Name
4. Custodian’s name
Number, street and apartment number
5. Custodian’s address
City
State
Zip Code + 4
6. Custodian’s SSN
7. Location of the
#1
#3
court that ordered
support payments for:
#2
8. Case or Docket number for:
9. Name of government agency to which you make payments for:
#1
#1
#2
#2
#3
#3
10. Address of
#1
the government
agency for:
#2
#3
11. Amount of
$
.00 per month
#1
$
.00 per month
#3
court ordered
payment
#2
$
.00 per month
12. Date payments were
#1 (MMDDYYYY)
#2 (MMDDYYYY)
#3 (MMDDYYYY)
ordered to start
#1
#2
#3
13. Total payments made during 2011
$
.00
$
.00
$
.00
14. Computation: Using the amount on Line 3 of Form D-40, find the correct Earned Income Credit (EIC) amount from the EIC table in the
Federal 1040 tax return booklet. Multiply that amount by .40 to determine the DC Non-Custodial Parent EITC amount to claim on Schedule U,
Part 1b, Line 1. If you are a part-year filer see page 18 of the D-40 booklet for instructions on prorating the credit to be claimed.
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Revised 09/11
2011 SCHEDULE N
P2
DC Non-Custodial Parent EITC Claim
File order 10
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