Form 1040AAdditional Dependents Statement                                               2013

Line 6cG Attach to return (after all IRS forms)Statement

Name(s) shown on returnYour social security number

Dependents:

                          (1)                                                                            (2)                                       (3)                                               (4)

 First name                   Last name                                Dependent's                  Dependent's                         b if qualifying

social security                  relationship                             child for

number                          to you                            child tax credit

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