Form 4622 - Worksheet For Determining Support printable pdf download

Michigan Department of Treasury

4622 (Rev. 10-10)

Worksheet for Determining Support

Issued under authority of Public Act 281 of 1967.

Keep a copy for your records. Refer to Internal Revenue Service (IRS) Publication 501 for detailed instructions on determining if you are a dependent.

Name

Tax Year

Social Security Number

Your tax return for the year noted in the enclosed letter indicates that you were claimed as a dependent on another person’s tax return. This

shows another person provided more than 50 percent of your financial support during the year. Your household income did not include that

support as other nontaxable income.

If you ARE a dependent, report the amount of support received on this form. Include copies of tuition statements and lease agreement(s).

The amount reported will be added to household income on your property tax credit and/or home heating credit claim, and the credit(s) will

be recalculated and processed. Do not submit an amended return.

If you are ARE NOT a dependent, complete this form and return with required documentation to support your claim. Written statements

without supporting documentation will not be accepted. Include a copy of the enclosed letter with your documentation. Do not submit an

amended return.

For assistance, call (517) 636-4486 or visit

Savings and Loans

1. Enter amount withdrawn from savings ..................................................................................................................

Name and address of the institution where savings account is located.

2. Enter amount borrowed .........................................................................................................................................

Name and address of person or institution you borrowed from. Attach copy of the loan agreement.

Household Expenses for the Residence(s) Claimed on your Property Tax and/or Home Heating Credit

3. Lodging (complete lines 3a, 3b, 3c and 3d):

3a. Did you own your home? Circle Yes or No.

3b. If you answered “Yes” to 3a, enter total mortgage paid for the year ...............................................................

3b.

3c. Enter the fair rental value of the home if you owned the home ......................................................................

3c.

3d. If you answered “No” to 3a, enter total rent paid for the year (provide copy of lease agreement) .................

3d.

4. Enter the total amount of utilities (heat, light, water, etc. not included in line 3c or 3d) .........................................

5. Enter the total amount of repairs (not included in line 3c or 3d) ............................................................................

6. Enter the total of other expenses (do not include mortgage interest, real estate taxes or insurance) .................

7. Add lines 3b through 6. These are the total household expenses .........................................................................

8. Enter total number of persons who lived in the household ....................................................................................

Your Expenses

9. Divide line 7 by line 8. This is your share of the household expenses ..................................................................

10. Enter your total clothing expenses ........................................................................................................................

10.

11. Enter your total food expenses ..............................................................................................................................

11.

12. Enter your total education expenses (include copies of tuition statements) ..........................................................

12.

13. Enter your total medical and dental expenses not paid for or reimbursed by insurance .......................................

13.

14. Enter your total travel and recreation expenses ....................................................................................................

14.

15. Enter the total of your other expenses...................................................................................................................

15.

16. Add lines 9 through 15. This is the total cost of your support for the year .............................................................

16.

Amount of Support From Others and/or Those Who Claimed You

17. Enter the amount of support provided by person claiming you as a dependent (for dependents only) ................

17.

18. Enter amounts provided by state, local, and other welfare societies or agencies .................................................

18.

19. Add lines 17 and 18. This is the amount you received for your support ................................................................

19.

Documentation required if claiming that you are not a dependent

• Copy of financial aid application showing your income is the only income included in the computation for financial aid eligibility.

• Copy of parent/qualified relative (who claimed you as a dependent) health insurance information showing you are not a dependent on

the health insurance plan.

Once you have completed this worksheet and obtained the required documentation, return the required documentation with a

copy of the Request for Information to the address noted in the letter.

Form 4622 - Worksheet For Determining Support

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