Schedule A1 Individual - Dependents And Beneficiaries Of Educational Contribution Accounts - 2004
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1Schedule A1 Individual
2004
Rev. 05.04
DEPENDENTS AND BENEFICIARIES OF EDUCATIONAL CONTRIBUTION ACCOUNTS
Taxable year beginning on __________________________________ , ________ and ending on ____________________________________ , ________
Social Security Number
Taxpayer’s name
Part I:
Dependents Information
55
(See instructions)
IMPORTANT INFORMATION PART I
Do not include the spouse on this schedule. A married individual who lives with his spouse is not a head of household for tax purposes, therefore, you should
not include the wife’s name in the box for head of household (line 01).
If a dependent entitles you the head of household filing status, do not claim him/her as a dependent.
In order to consider the exemption for dependents you must include this schedule with your return.
Relationship
*
Social Security Number
Last
Second Last
Category
Date of Birth
Name, Initial
Name
Name
(N) (U) (I)
Day
Month
Year
Head of Household
J
(01)
NOT TAXPAYER / NOT SPOUSE
(02)
(03)
(04)
(05)
(06)
(07)
(08)
(09)
(10)
*
See instructions.
Part II:
57
Beneficiaries of Educational Contributions Accounts
(See instructions)
IMPORTANT INFORMATION PART II
These beneficiaries must not be considered to determine the exemption for dependents. However, if any of these beneficiaries qualifies as your dependent,
you must include him/her in Part I of this Schedule.
Last
Second Last
Date of Birth
Relationship
Social Security Number
Contributed Amount
Name, Initial
Name
Name
Day
Month
Year
(01)
.
0
0
,
(02)
.
0
0
,
(03)
.
0
0
,
(04)
.
0
0
,
(05)
.
0
0
,
Total contributions (Add lines (01) through (05) and transfer to Part 3, line 6H of the Short Form) ........................................
(10)
.
0
0
,
Conservation Period: Ten (10) Years
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