OMB No. 1545-0074
Form
2120
(Rev. October 2005)
Multiple Support Declaration
Attachment
Sequence No.
114
Department of the Treasury
Internal Revenue Service

Attach to Form 1040 or Form 1040A.
Your social security number
Name(s) shown on return
During the calendar year
, 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 ye
ar
that began in the above calendar year.
Social security number
Eligible person’s name
Address (number, street, apt. no., city, state, and ZIP code)
Form
2120
(Rev. 10-2005)
Cat. No. 11712F
Social security number
Eligible person’s name
Address (number, street, apt. no., city, state, and ZIP code)
Social security number
Eligible person’s name
Address (number, street, apt. no., city, state, and ZIP code)
Social security number
Eligible person’s name
Address (number, street, apt. no., city, state, and ZIP code)
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