Form 8867 - Paid Preparer'S Earned Income Credit Checklist - 2012 Page 4
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Form 8867 (2012)
Page
26
Which documents below, if any, did you rely on to determine EIC eligibility for the qualifying child(ren) listed on Schedule EIC?
Check all that apply. Keep a copy of any documents you relied on. See the instructions before answering. If there is no
qualifying child, check box a. If there is no disabled child, check box o.
Residency of Qualifying Child(ren)
i
a No qualifying child
Place of worship statement
b School records or statement
j
Indian tribal official statement
c Landlord or property management statement
k Employer statement
d Health care provider statement
l
Other (specify)
e Medical records
f Child care provider records
g Placement agency statement
h Social service records or statement
m Did not rely on any documents, but made notes in file
n Did not rely on any documents
Disability of Qualifying Child(ren)
o No disabled child
s Other (specify)
p Doctor statement
q Other health care provider statement
r Social services agency or program statement
t Did not rely on any documents, but made notes in file
u Did not rely on any documents
27
If a Schedule C is included with this return, which documents or other information, if any, did you rely on to confirm the
existence of the business and to figure the amount of Schedule C income and expenses reported on the return? Check all that
apply. Keep a copy of any documents you relied on. See the instructions before answering. If there is no Schedule C, check
box a.
Documents or Other Information
a No Schedule C
h Bank statements
b Business license
i
Reconstruction of income and expenses
c Forms 1099
j
Other (specify)
d Records of gross receipts provided by taxpayer
e Taxpayer summary of income
f Records of expenses provided by taxpayer
k Did not rely on any documents, but made notes in file
g Taxpayer summary of expenses
l
Did not rely on any documents
You have complied with all the due diligence requirements if you:
▶
1. Completed the actions described on lines 20 and 21 and checked "Yes" on those lines,
2. Completed the actions described on lines 22, 23, 24, and 25 (if they apply) and checked "Yes" (or "Does not apply") on
those lines,
3. Submit Form 8867 in the manner required, and
4. Keep all five of the following records for 3 years from the latest of the dates specified in the instructions under Document
Retention:
a. Form 8867, Paid Preparer's Earned Income Credit Checklist,
b. The EIC worksheet(s) or your own worksheet(s),
c. Copies of any taxpayer documents you relied on to determine eligibility for or amount of EIC,
d. A record of how, when, and from whom the information used to prepare the form and worksheet(s) was obtained, and
e. A record of any additional questions you asked and your client's answers.
If you checked “No” on line 20, 21, 22, 23, 24, or 25, you have not complied with all the due diligence requirements and may
▶
have to pay a $500 penalty for each failure to comply.
8867
Form
(2012)
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