Form 8836

Department of the Treasury

Internal Revenue Service

Qualifying Children Residency Statement

 See instructions beginning on page 2.

OMB No. 1545-1829

Attachment

Sequence No. 136

Taxpayer Information

Your first name and initial Last name Your social security number

If you are filing a joint return for 2003, spouse’s first name

and initial

Spouse’s social security number

Home address (number and street). If you have a P.O. box, see instructions

City, town or post office, state, and ZIP code Your evening phone number

( )

Qualifying Children Information

Caution. Enter each child’s first and last name exactly as it appears on the child’s social security card.

Child 1

Child 2

Child’s first name Last name Child’s social security number

Proof of Residency (see instructions)

Check one or more boxes below and attach any required documents. The combined documents must include your name,

the child’s name, street address, and dates the child lived with you to show that you and the child lived together for more

than half of 2003. See Residency Test on page 2 for details and exceptions. For details on who can provide documents,

see page 3.

I have attached copies of one or more of the following records (see page 3 to find out which records to send and the

information these records must contain):

I have attached a signed letter on official letterhead (original or copy) from one or more of the following third parties (see

page 3 for details on the information the letter must contain):

Under penalties of perjury, I declare that I have examined this statement, and to the best of my knowledge and belief, it is true,

correct, and complete.

Date 

For Paperwork Reduction Act Notice, see page 4. Cat. No. 14955C Form 8836 (2003)

Part III

Part I

Part II

Last name

Child’s first name Last name



 Child’s social security number

2003

Your daytime phone number

( )

Taxpayer

Sign Here 

Note. The IRS may contact any person or organization that provides documents you attach to this form.

(for the earned income credit)

One or more third parties have completed the Third Party Affidavit, which I have attached. If the affidavit(s) shows that

you have met the residency test, do not check any other boxes or attach additional information.

Date 

Spouse Named in

Part I Sign Here 

Child-care records

Community-based organization records

Court or placement agency records

Employment records

Indian tribal records

Law enforcement reports

Legal records

Leases

Medical records

Religious records

School records

Social service agency records

Attorney

Child-care provider

Clergy

Community-based organization official

Court or placement agency official

Employer

Health-care provider

Indian tribal official

Landlord or property manager

School official

Social service agency or

other government official

Utility company

Utility bills

Law enforcement officer

 Esta forma está disponible en español. Por favor, llame al 1-800-294-2723.

Note. The Third Party Affidavit was sent to you with Form 8836 and is designated as either Schedule A (Form 8836)

or Schedule B (Form 8836). Use only the version of the schedule you received with Form 8836.
Pre-recorded information about the EIC is also

available by phone 24 hours a day, 7 days a week. Call

1-800-829-4477 and select TeleTax topic No. 601.

Have paper and a pen or pencil handy to take notes.

Form 8836 (2003) Page 2

Instructions

Purpose of Form

Use Form 8836 if the IRS sent this form to you and

you have a qualifying child for the earned income

credit (EIC) for 2003. A qualifying child is one who

meets the age, relationship, and residency tests for the

EIC. We need this form to show that you and your

child met the residency test (defined on this page) for

2003. Residency Test

Your child must have lived with you in the United

States for more than half of 2003 (at least 183 days).

Include the time that you or your child are temporarily

apart due to a special circumstance, such as military

service, school attendance, hospitalization, or juvenile

detention. It does not matter where you lived with your

child. For example, you may live with your child in a

homeless shelter. For more details on the residency

test, see Pub. 596.

Where To File

You cannot file Form 8836 electronically. However, you

may still file your tax return electronically. If you do so,

send Form 8836 and all required attachments to:

Internal Revenue Service

Stop 4300, Annex R2

Kansas City, MO 64999-0065

We will review the information you send us. We will

send you a letter to let you know if you have met the

residency test. If we need more information, we will

contact you.

What We Will Do After We Receive This

Form

How To Get Help

Call 1-800-294-2723 if you need help completing this form or you cannot get the documents you need to send

with this form. Help is available Monday through Friday from 8:00 a.m. to 11:00 p.m. Eastern time.

For details on the EIC eligibility rules, see Pub. 596,

Earned Income Credit (EIC). You can order Pub. 596 by

calling 1-800-TAX-FORM (1-800-829-3676) or you can

download it from the IRS website at www.irs.gov.

Who Must File

File this form only if:

● You are claiming the EIC with a qualifying child for

2003.

● The IRS sent this form to you with a letter directing

you to file it and

You may also visit any IRS Taxpayer Assistance Center. To find out the location and hours of the nearest

center, call 1-800-829-1040 or visit the IRS website at www.irs.gov/localcontacts. You also can contact the

Taxpayer Advocate Service at 1-877-777-4778 or the local Taxpayer Advocate office in your area.

If you are required to, but do not file Form 8836, the

IRS will not allow the EIC with a qualifying child for

2003. If the IRS does not allow your EIC, we will notify

you of your appeal rights.

If you do not meet the residency test for one or more

of your children, we will send you a letter to let you

know. The IRS will not allow the EIC based on that

child. If you have other children for whom you can

provide documents, you will have the opportunity

to do so. If the IRS does not allow all of your EIC, we

will notify you of your appeal rights.

Special Rule For a Child Who Was Born or Died in

2003. A child is considered to have lived with you for

more than half of 2003 if the child was born or died in

2003 and your home was the child’s home for the

entire time he or she was alive in 2003.

If you move after you file Form 8836, notify us in

writing of your new address. To do this, use Form

8822, Change of Address.

Electronic Filers

Do not file Form 8836 if you do not meet the

residency test for 2003, because we will not allow the

EIC based on a qualifying child.

Attach this form to your 2003 tax return and file it at

the applicable address shown below (and not at the

address listed in your tax return instructions if that is a

different address).

IF you are filing . . . THEN use this address if you:

Form 1040

Form 1040A

Are not enclosing a payment . . . Are enclosing a payment . . .

Internal Revenue Service Center

Kansas City, MO 64999-0002

Internal Revenue Service Center

Kansas City, MO 64999-0102

Internal Revenue Service Center

Kansas City, MO 64999-0015

Internal Revenue Service Center

Kansas City, MO 64999-0115
Form 8836 (2003) Page 3

What Kind of Documents You Must Provide. You

may provide any of the following:

● A copy of a record (such as school records, medical

records, child-care records, a lease, or a pay stub).

● A signed letter on official letterhead (original or

copy).

What the Documents Must Show. If you send an

official record or letter, it must clearly show:

● Your name, your child’s name, or both names, and

● A street address and the dates that you or your child

lived at that address during 2003, and

● The name, address, and phone number of the person

or organization that provided the record or letter.

If you and your spouse are filing a joint return, you

only need to show that one of you lived with your child

for more than half of 2003.

Who Can Provide Documents to You. You may

submit a Third Party Affidavit from any third party

eligible to complete the affidavit or other documents

from any of the following third parties (other than you,

your spouse, your dependent, your qualifying child for

the earned income credit, or a parent of that qualifying

child).

● School official (such as a teacher, principal, or

administrative assistant). A school includes Head Start,

pre-K programs, and before or after school care

provided by a school.

● Health-care provider (such as your doctor, your

nurse practitioner, or a clinic official).

● Member of the clergy (such as your minister, priest,

rabbi, or imam).

● Child-care provider who is age 18 or older.

● Your employer.

● Landlord or property manager (including a building

superintendent, public housing official, or rental agent).

● Social service agency or other government official

(such as a case worker at a public assistance office or

operator of a homeless shelter).

● Community-based organization official (such as an

official from the YMCA, YWCA, Boy Scouts, Girl

Scouts, Boys and Girls Clubs, 4-H, Little League,

Police Athletic League, immigrant advocacy groups,

neighborhood associations, homeowners and

condominium associations, and other non-profit

groups).

Part III

You must attach a Third Party Affidavit or other

documents showing that each qualifying child listed on

Schedule EIC lived with you for more than half of

2003. You may need to send more than one affidavit or

other document to show that your child lived with you

for more than half of 2003.

● An individual taxpayer identification number (ITIN),

which the IRS issues to noncitizens who cannot get an

SSN or

For EIC purposes, a valid SSN is a number issued by

the Social Security Administration unless “Not Valid for

Employment” is printed on the social security card and

the number was issued solely to receive a Federally

funded benefit.

● Indian tribal official.

● Utility company (such as an electric or gas

company).

Your qualifying child must have a valid social security

number (SSN), unless the child was born and died in

2003. If the qualifying child was born and died in 2003

and did not have an SSN, attach a copy of that child’s

birth certificate to Form 8836 and enter “Died” instead

of the child’s SSN.

Be sure that any child named on this form is your

qualifying child and you are claiming that child on

Schedule EIC of your 2003 tax return.

Part II

P.O. Box. Enter your box number only if your post

office does not deliver mail to your home. Otherwise,

enter your home street address.

Daytime and Evening Phone Numbers. Providing

your daytime and evening phone numbers may help

speed the processing of this form. We may have

questions about the information you provided. By

answering our questions over the phone, we may be

able to continue processing the form without mailing

you a letter. You may list a mobile phone number as

your daytime or evening phone number (or both). If you

will be filing a joint return, you may enter either

spouse’s phone numbers.

Part I

● An adoption taxpayer identification number (ATIN),

which the IRS issues to adopting parents who cannot

get an SSN for the child being adopted until the

adoption is final.

We will not allow the EIC based on a qualifying child

who has, instead of an SSN:

● Attorney who handled your divorce or child custody

case.

● Official of the court or agency that issued a decision

or order involving your divorce or custody, support, or

placement of your child.

● Law enforcement officer (such as a police officer or

parole officer).

If you or your child were temporarily absent from

home, attach documents showing the special

circumstances of the absence. For example, if you

were away from home on military duty, attach a copy

of your military orders showing the dates you were

away and where you were stationed.

If you cannot obtain a completed Third Party

Affidavit, records, or a signed letter from one or

more third parties to show that your child lived

with you for more than half of 2003, call

1-800-294-2723 and we will help you.

● The Third Party Affidavit. Use only the version of the

affidavit (schedule) you received with Form 8836.
Form 8836 (2003) Page 4

Signing the Form. You must sign and date Part III

under penalties of perjury before you send it to us with

the documents. Criminal penalties may be imposed for

making a false statement.

Example 3. You attach seven electric bills from the

Edison Electric Company for the months of January

through May, September, and October of 2003

showing your name and address on them. You also

attach transcripts of your child’s grades from the

Roosevelt Grade School showing your child’s name

and the same address shown on your electric bills. The

transcripts cover the periods January through May

2003 and September through November 2003. You

check the second box in Part III. Because you have

shown that the total time you and your child lived

together was more than half the year, the residency

test is met.

Example 2. You attach a transcript of your child’s

grades from the Washington Elementary School

showing that your child lived with you from January 1,

2003, through May 31, 2003. You also attach a letter

on official letterhead from the principal of the Lincoln

Middle School. The letter shows the dates of school

attendance and that the child’s address was the same

as yours. The letter covers the period from September

1, 2003, through December 31, 2003. You check the

second and third boxes in Part III. Because the total

time shown is more than half of the year, the residency

test is met.

Example 1. You attach a letter on official letterhead

from Acme Medical Clinic showing that your child lived

with you from January 1, 2003, through March 31,

2003. You also have Reverend Smith, your clergyman,

complete a Third Party Affidavit showing that you and

your child lived together from April 1, 2003, through

July 31, 2003. You check the first and third boxes in

Part III. Because the total time shown is more than half

of the year, the residency test is met.

● One document that shows that both you and your

child lived at the same address for more than half of

2003.

● One document that shows that you and your child

lived at the same address for part of 2003 and a

second document that shows that you and your child

lived together for the remainder of 2003.

● One document that shows that you lived at an

address for more than half of 2003 and a second

document that shows that your child lived at the same

address during the same period of time.

● If you have two children, separate documents for

each child to show that each one lived with you for

more than half of 2003.

● If you have two children, one document to show that

both of your children lived with you for more than half

of 2003.

Here are examples of acceptable document

combinations:

Paperwork Reduction Act Notice. We ask for the

information on this form to carry out the Internal Revenue

laws of the United States. You are required to give us

the information. We need it to ensure that you are

complying with these laws and to allow us to figure and

collect the right amount of tax.

You are not required to provide the information

requested on a form that is subject to the Paperwork

Reduction Act unless the form displays a valid OMB

control number. Books or records relating to a form or

its instructions must be retained as long as their contents

may become material in the administration of any Internal

Revenue law. Generally, tax returns and return

information are confidential, as required by Internal

Revenue Code section 6103.

The time needed to complete and file this form will vary

depending on individual circumstances. The estimated

average time is:

If you have comments concerning the accuracy of

these time estimates or suggestions for making this form

simpler, we would be happy to hear from you. You can

write to the Tax Products Coordinating Committee,

Western Area Distribution Center, Rancho Cordova, CA

95743-0001. Do not send the form to this address.

Instead, see Where To File on page 2.

How Many Documents Do You Need? You may

submit any combination of the documents listed on

page 3 as long as they show, when taken together,

that you lived with your child for more than half of

2003. In some cases, a single document will show that

you and your child lived at the same address. In other

cases, you may need to provide one document

showing your name and address as well as a second

document showing your child’s name with the same

address. You may need more than one document to

show that your address and your child’s address were

the same for more than half of 2003.

Form 8836 Schedule A Schedule B

Recordkeeping 6 min. - - - - - - - - - -

Learning about the

law or the form 14 min. 5 min. 4 min.

Preparing the form 11 min. 12 min. 18 min.

Copying,

assembling, and

sending the form to

the IRS 20 min. 20 min. 20 min.