Form 2120 Multiple Support Declaration

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I.R.S. SPECIFICATIONS
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FORM 2120, PAGE 1 of 2 (PAGE 2 IS BLANK)
MARGINS: TOP 13mm (1⁄2 "), CENTER SIDES.
PRINTS: FACE ONLY
PAPER: WHITE WRITING, SUB. 20. INK: BLACK
FLAT SIZE: 203mm (8")
279mm (11")
PERFORATE: (NONE)
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2120

(Rev. October 2005)
Department of the Treasury
Internal Revenue Service

Action

Date

O.K. to print
Revised proofs
requested

OMB No. 1545-0074

Multiple Support Declaration
䊳

Attachment
Sequence No.

Attach to Form 1040 or Form 1040A.

Name(s) shown on return

During the calendar year

Signature

114

Your social security number

, the eligible persons listed below each paid over 10% of the support of:

Name of your qualifying relative

I have a signed statement from each eligible person waiving his or her right to claim this person as a dependent for any tax year
that began in the above calendar year.
Eligible person’s name

Social security number

Address (number, street, apt. no., city, state, and ZIP code)

Eligible person’s name

Social security number

Address (number, street, apt. no., city, state, and ZIP code)

Eligible person’s name

Social security number

Address (number, street, apt. no., city, state, and ZIP code)

Eligible person’s name

Social security number

Address (number, street, apt. no., city, state, and ZIP code)

Instructions

Note. To find out what is included in support, see Pub. 501,
Exemptions, Standard Deduction, and Filing Information.

What’s New

Signed Statement

The rules for multiple support agreements still apply to claiming an
exemption for a qualifying relative, but they no longer apply to
claiming an exemption for a qualifying child. For the definitions of
“qualifying relative” and “qualifying child,” see your tax return
instruction booklet.

You must have received, from each other eligible person listed
above, a signed statement waiving his or her right to claim the
person as a dependent for the calendar year indicated on this form.
The statement must include:
● The calendar year the waiver applies to,
● The name of your qualifying relative the eligible person helped to
support, and

Purpose of Form
Use Form 2120 to:
● Identify each other eligible person (see below) who paid over 10%
of the support of your qualifying relative whom you are claiming as a
dependent, and
● Indicate that you have a signed statement from each other eligible
person waiving his or her right to claim that person as a dependent.
An eligible person is someone who could have claimed a person
as a dependent except that he or she did not pay over half of that
person’s support.
If there are more than four other eligible persons, attach a
statement to your return with the required information.

Claiming a Qualifying Relative
Generally, to claim a person as a qualifying relative, you must pay
over half of that person’s support. However, even if you did not meet
this support test, you may be able to claim him or her as a
dependent if all five of the following apply.
1. You and one or more other eligible person(s) (see above)
together paid over half of that person’s support.
2. You paid over 10% of the support.
3. No one alone paid over half of that person’s support.
4. The other dependency tests are met. See Step 4, Is Your
Qualifying Relative Your Dependent? in the Form 1040 or Form
1040A instructions.
5. Each other eligible person who paid over 10% of the support
agrees not to claim that person as a dependent by giving you a
signed statement. See Signed Statement on this page.

● The eligible person’s name, address, and social security number.
Do not file the signed statement with your return. But you must keep
it for your records and be prepared to furnish it and any other
information necessary to show that you qualify to claim the person
as your dependent.

Additional Information
See Pub. 501 for details.
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 average time and expenses required to complete and file this form
will vary depending on individual circumstances. For the estimated
averages, see the instructions for your income tax return.
If you have suggestions for making this form simpler, we would be
happy to hear from you. See the instructions for your income tax return.

Cat. No. 11712F

Form

2120

(Rev. 10-2005)