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General


1.Filing Status
?

Check here if you are 65 or older.
Check here if you are permanently blind.
Check here if spouse is 65 or older.
Check here if your spouse is permanently blind.

2.Number of Exemptions
?

Include 1 for yourself unless you are claimed by another person, 1 for your spouse (if applicable), and 1 for each dependent child.

3.Children Info
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Enter the number of children included in line 2 that are under age 17.

4.Health Coverage
A. Number of adults without health care coverage.
B. Number of children without health care coverage.

5.Earned Income Credit
A. Number of children under age 19.
B. Number of children over age 18 and under the age of 24 that are full time students.
C. Number of children over age 18 and disabled.