HOUSEHOLD EMPLOYEE INCOME AFFIDAVIT
Anderson Tax Experts (A.T.E.)
TAXPAYER INFORMATION
Taxpayer Name:
Spouse Name (if filing jointly):
Address:
City, State & ZIP:
Phone Number:
Tax Year(s):
SERVICES PROVIDED
Check all services performed:
Services Performed
Babysitting / Nanny
House Cleaning / Maid
Eldercare / Companion Care
Meal Preparation
Driver / Errands
Yard Work / Landscaping
House-sitting
Handyman / General Help
Other:
HOUSEHOLD EMPLOYERS & INCOME RECEIVED
Please note You can only make $2600 per household
Employer 1
Employer Name & Address:
Services Provided:
Total Paid: $
Date of Last Payment:
-
Month
-
Day
Year
Date
Employer 2
Employer Name & Address:
Services Provided:
Total Paid: $
Date of Last Payment:
-
Month
-
Day
Year
Date
Employer 3
Employer Name & Address:
Services Provided:
Total Paid: $
Date of Last Payment:
-
Month
-
Day
Year
Date
Employer 4
Employer Name & Address:
Services Provided:
Total Paid: $
Date of Last Payment:
-
Month
-
Day
Year
Date
Employer 5
Employer Name & Address:
Services Provided:
Total Paid: $
Date of Last Payment:
-
Month
-
Day
Year
Date
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Employer 6
Employer Name & Address:
Services Provided:
Total Paid: $
Date of Last Payment:
-
Month
-
Day
Year
Date
Employer 7
Employer Name & Address:
Services Provided:
Total Paid: $
Date of Last Payment:
-
Month
-
Day
Year
Date
Employer 8
Employer Name & Address:
Services Provided:
Total Paid: $
Date of Last Payment:
-
Month
-
Day
Year
Date
Total Household Income for Year: $
INCOME EXPLANATION SUMMARY (REQUIRED)
Provide details including •Frequency of payment (daily, weekly, per job) • Payment amounts. • Payment method (cash, CashApp, Zelle, Venmo, etc.). • Any missing or unverifiable records. •Breakdown of earnings by employer
AFFIDAVIT & CERTIFICATION
I certify that all information in this affidavit is true and complete to the best of my knowledge. I understand that providing false information may result in penalties under federal or state law. I authorize Anderson Tax Experts (A.T.E.) to use this information to prepare my tax return.
Taxpayer Signature:
Date:
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Month
-
Day
Year
Date
Spouse Signature (if filing jointly):
Date:
-
Month
-
Day
Year
Date
Tax Preparer Signature:
Date:
-
Month
-
Day
Year
Date
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