Massachusetts Form 1 - Schedule X, Schedule Y, Schedule Z, Schedule Di - 2013 Page 3

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File pg. 4
SOCIAL SECURITY NUMBER
Schedule DI Dependent Information.
2013
Enclose with Form 1 or Form 1-NR/PY. Do not cut or separate these schedules.
You must complete this schedule if you are claiming a dependent exemption(s) on Form 1, line 2b or Form 1-NR/PY, line 4b or taking a deduction/
credit(s) on Form 1, lines 12, 13 or 40 or Form 1-NR/PY, lines 16, 17 or 45. Complete information below for each dependent. Do not include yourself
or your spouse. If you are claiming more than 10 dependents, see instructions.
1. SOCIAL SECURITY NUMBER
1. FIRST NAME
M.I.
LAST NAME
DATE OF BIRTH
RELATIONSHIP TO TAXPAYER
IS DEPENDENT A QUALIFYING CHILD FOR EARNED INCOME CREDIT?
Yes
3
2. SOCIAL SECURITY NUMBER
2. FIRST NAME
M.I.
LAST NAME
DATE OF BIRTH
RELATIONSHIP TO TAXPAYER
IS DEPENDENT A QUALIFYING CHILD FOR EARNED INCOME CREDIT?
Yes
3
3. SOCIAL SECURITY NUMBER
3. FIRST NAME
M.I.
LAST NAME
DATE OF BIRTH
RELATIONSHIP TO TAXPAYER
IS DEPENDENT A QUALIFYING CHILD FOR EARNED INCOME CREDIT?
Yes
3
4. SOCIAL SECURITY NUMBER
4. FIRST NAME
M.I.
LAST NAME
DATE OF BIRTH
RELATIONSHIP TO TAXPAYER
IS DEPENDENT A QUALIFYING CHILD FOR EARNED INCOME CREDIT?
Yes
3
5. SOCIAL SECURITY NUMBER
5. FIRST NAME
M.I.
LAST NAME
DRAFT AS OF
DATE OF BIRTH
RELATIONSHIP TO TAXPAYER
IS DEPENDENT A QUALIFYING CHILD FOR EARNED INCOME CREDIT?
SEPTEMBER 18, 2013
Yes
3
(SUBJECT TO CHANGE)
6. SOCIAL SECURITY NUMBER
6. FIRST NAME
6
M.I.
LAST NAME
DATE OF BIRTH
RELATIONSHIP TO TAXPAYER
IS DEPENDENT A QUALIFYING CHILD FOR EARNED INCOME CREDIT?
Yes
3
7. SOCIAL SECURITY NUMBER
7. FIRST NAME
M.I.
LAST NAME
DATE OF BIRTH
RELATIONSHIP TO TAXPAYER
IS DEPENDENT A QUALIFYING CHILD FOR EARNED INCOME CREDIT?
Yes
3
8. SOCIAL SECURITY NUMBER
8. FIRST NAME
M.I.
LAST NAME
DATE OF BIRTH
RELATIONSHIP TO TAXPAYER
IS DEPENDENT A QUALIFYING CHILD FOR EARNED INCOME CREDIT?
Yes
3
9. SOCIAL SECURITY NUMBER
9. FIRST NAME
M.I.
LAST NAME
DATE OF BIRTH
RELATIONSHIP TO TAXPAYER
IS DEPENDENT A QUALIFYING CHILD FOR EARNED INCOME CREDIT?
Yes
3
10. SOCIAL SECURITY NUMBER
10. FIRST NAME
M.I.
LAST NAME
DATE OF BIRTH
RELATIONSHIP TO TAXPAYER
IS DEPENDENT A QUALIFYING CHILD FOR EARNED INCOME CREDIT?
Yes
3

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