42126Annex F Waiver 2

Annex “F”
SWORN DECLARATION AND WAIVER OF RIGHT
TO CLAIM EXEMPTIONS OF QUALIFIED DEPENDENT CHILDREN

In accordance with the provisions of Section 29 (1) (2) (A) of the National Internal Revenue Code, as amended, I Mr. hereby voluntarily depose and say:
1. That my wife is the income earner;
2. That she file an income tax return on her taxable income;
3. That I am a (check pls):  unemployed; ___ self-employed: ___ engaged in business; ___ practice profession;
4. That this waiver will be effective for the taxable year 2014 and shall continue for the succeeding years unless sooner revoked;
5. That I hereby waive my right to claim the additional exemption for all our qualified dependent children in favor of my wife presently employed with:
Name of wife:
Name of wife’s employer
Address of employer _
TIN of employer __Tel No. _____________________ Fax No. _______________________

Name of qualified dependent child(ren)
Date of Birth (mm/dd/yyyy)
1

2

3

4

I hereby declared under penalties of perjury that the foregoing representations are true and correct and that the waiver of right is voluntarily and knowingly made in accordance with the provisions of the National Internal Revenue Code, as amended.
____________ ____________________ _______________________
(Signature of husband over printed name) TIN Date
________________________________________________________________________________________________
ACKNOWLEDGEMENT OF HUSBAND’S EMPLOYER

Name of husband’s employer________________________________________________________________________
Address of employer ______________________________________________________________________________
TIN of employer________________________ Tel No. __________________ Fax No. _________________________

____________________________________________ ___________________________
(Signature over printed name