1040

Department of the Treasury—Internal Revenue Service

U.S. Individual Income Tax Return 2023 OMB No. 1545-0074 IRS Use Only—Do not write or staple in this space.

For the year Jan. 1–Dec. 31, 2023, or other tax year beginning , 2023, ending , 20 See separate instructions.
Your first name and middle initial Last name Your social security number
ROBERTO NIEVES 598-60-2066
If joint return, spouse's first name and middle initial Last name Spouse's social security number
VICTORIA MALDONADO 597-66-3380
Home address (number and street). If you have a P.O. box, see instructions. Apt. no. Presidential Election Campaign
256 MICHIGAN AVE 415-A Check here if you, or your
spouse if filing jointly, want $3
City, town, or post office. If you have a foreign address, also complete spaces below. State ZIP code
to go to this fund. Checking a
WATERTOWN NY 13601- box below will not change
Foreign country name Foreign province/state/county Foreign postal code your tax or refund.
You Spouse

Filing Status Single Head of household (HOH)

Check only X Married filing jointly (even if only one had income)
one box.
Married filing separately (MFS) Qualifying surviving spouse (QSS)
If you checked the MFS box, enter the name of your spouse. If you checked the HOH or QSS box, enter the child's name if the qualifying person is
a child but not your dependent:

Digital At any time during 2023, did you: (a) receive (as a reward, award, or payment for property or services); or (b) sell,
Assets exchange, or otherwise dispose of a digital asset (or a financial interest in a digital asset)? (See instructions.) . . . Yes X No

Standard Someone can claim: You as a dependent Your spouse as a dependent

Deduction Spouse itemizes on a separate return or you were a dual-status alien

Age/Blindness You: Were born before January 2, 1959 Are blind Spouse: Was born before January 2, 1959 Is blind
Dependents (see instructions): (2) Social security (3) Relationship (4) Check the box if qualifies for (see instructions):
(1) First name Last name number to you Child tax credit Credit for other dependents
If more
than four ADYAN M NIEVES-MALDONAD 714-43-8305 DAUGHTER X
dependents,
see instructions
and check
here . .
Income 1a Total amount from Form(s) W-2, box 1 (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . 1a 62,027
Attach Form(s) b Household employee wages not reported on Form(s) W-2 . . . . . . . . . . . . . . . . . . . . . . . . . . 1b
W-2 here. Also c Tip income not reported on line 1a (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1c
attach Forms
W-2G and d Medicaid waiver payments not reported on Form(s) W-2 (see instructions) . . . . . . . . . . . . . . . . . . . . 1d
1099-R if tax e Taxable dependent care benefits from Form 2441, line 26 . . . . . . . . . . . . . . . . . . . . . . . . . . 1e
was withheld. f Employer-provided adoption benefits from Form 8839, line 29 . . . . . . . . . . . . . . . . . . . . . . . . . 1f

If you did not g Wages from Form 8919, line 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1g

get a Form h Other earned income (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1h
W-2, see i Nontaxable combat pay election (see instructions) . . . . . . . . . . . . . . . . . 1i
instructions.
z Add lines 1a through 1h . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1z 62,027
Attach Sch. B 2a Tax-exempt interest . . . . . . 2a b Taxable interest . . . . . . . . . . . . 2b
if required. 3a Qualified dividends . . . . . . . 3a b Ordinary dividends. . . . . . . . . . . . . 3b
4a IRA distributions . . . . . . . 4a b Taxable amount . . . . . . . . . . . 4b
Standard 5a Pensions and annuities . . . . . 5a b Taxable amount . . . . . . . . . . . 5b
Deduction for—
6a Social security benefits . . . 6a b Taxable amount . . . . . . . . . . . 6b
• Single or
Married filing c If you elect to use the lump-sum election method, check here (see instructions) . . . . . . . . . . . . . . .
separately,
$13,850 7 Capital gain or (loss). Attach Schedule D if required. If not required, check here . . . . . . . . . . . . . . . 7
• Married filing
8 Additional income from Schedule 1, line 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
jointly or
Qualifying 9 Add lines 1z, 2b, 3b, 4b, 5b, 6b, 7, and 8. This is your total income . . . . . . . . . . . . . . . . . . . . . . . 9 62,027
surviving spouse,
$27,700 10 Adjustments to income from Schedule 1, line 26 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
• Head of 11 Subtract line 10 from line 9. This is your adjusted gross income . . . . . . . . . . . . . . . . . . . . . . . . 11 62,027
household,
$20,800 12 Standard deduction or itemized deductions (from Schedule A) . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 27,700
• If you checked
any box under
13 Qualified business income deduction from Form 8995 or Form 8995-A . . . . . . . . . . . . . . . . . . . . . 13 0
Standard 14 Add lines 12 and 13 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 27,700
Deduction,
see instructions. 15 Subtract line 14 from line 11. If zero or less, enter -0-. This is your taxable income . . . . . . . . . . . 15 34,327
For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions. Form 1040 (2023)
BCA
Form 1040 (2023) ROBERTO NIEVES & VICTORIA MALDONADO 598-60-2066 Page 2
Tax and 16 Tax (see instructions). Check if any from Form(s): 1 8814 2 4972 3 . . . 16 3,679
Credits 17 Amount from Schedule 2, line 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
18 Add lines 16 and 17 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 3,679
19 Child tax credit or credit for other dependents from Schedule 8812 . . . . . . . . . . . . . . . . . . . . . . . . 19 22
20 Amount from Schedule 3, line 8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 3,657
21 Add lines 19 and 20 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 3,679
22 Subtract line 21 from line 18. If zero or less, enter -0- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
23 Other taxes, including self-employment tax, from Schedule 2, line 21 . . . . . . . . . . . . . . . . . . . . . . . 23
24 Add lines 22 and 23. This is your total tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Payments 25 Federal income tax withheld from:
a Form(s) W-2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25a
b Form(s) 1099 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25b
c Other forms (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . 25c
d Add lines 25a through 25c . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25d

If you have a 26 2023 estimated tax payments and amount applied from 2022 return . . . . . . . . . . . . . . . . . . . . 26
qualifying child, 27 Earned income credit (EIC) . . . . . NO
. . . . . . . . . . . . . . . . . . . . . . 27
attach Sch. EIC.
28 Additional child tax credit from Schedule 8812 . . . . . . . . . . . . . . . . . . . 28 1,600
29 American opportunity credit from Form 8863, line 8 . . . . . . . . . . . . . . . . . 29
30 Reserved for future use . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
31 Amount from Schedule 3, line 15 . . . . . . . . . . . . . . . . . . . . . . . . . 31
32 Add lines 27, 28, 29, and 31. These are your total other payments and refundable credits . . . . . . . . . . . . . . 32 1,600
33 Add lines 25d, 26, and 32. These are your total payments . . . . . . . . . . . . . . . . . . . . . . . . . 33 1,600
34 If line 33 is more than line 24, subtract line 24 from line 33. This is the amount you overpaid . . . . . . . . . . . . . . 34 1,600
Refund
35a Amount of line 34 you want refunded to you. If Form 8888 is attached, check here . . . . . . . . . . . . . . . 35a 1,600
Direct deposit? 256074974 c Type: X Checking Savings
b Routing number
See instructions.
d Account number 7118616148
36 Amount of line 34 you want applied to your 2024 estimated tax . . . . . . . . . . . . . 36
Amount 37 Subtract line 33 from line 24. This is the amount you owe.
You Owe For details on how to pay, go to www.irs.gov/Payments or see instructions . . . . . . . . . . . . . . . . . . . . . 37
38 Estimated tax penalty (see instructions) . . . . . . . . . . . . . . . . . . . . . . 38
Third Party Do you want to allow another person to discuss this return with the IRS?
Designee See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes. Complete below. X No
Designee's Phone Personal identification
name no. number (PIN)

Sign Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge and
belief, they are true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Here Your signature Date Your occupation If the IRS sent you an Identity Protection
PIN, enter it
Joint return? MILITAR here (see inst.)
See instructions. Spouse's signature. If a joint return, both must sign. Date Spouse's occupation If the IRS sent you an Identity Protection
Keep a copy for PIN, enter it
your records. MILITAR here (see inst.)

Phone no. 787-341-4745 Email address [email protected]

Preparer's name Preparer's signature Date PTIN Check if:
Paid X Self-employed
ANGEL M CINTRON MORAL ANGEL M CINTRON MORALES 01/29/2024 P01787029
Preparer
Firm's name G A ACCOUNTING SERVICES Phone no. 787-934-3277
Use Only Firm's address BO PALOMAS CARR 779 KM 7 COMERIO PR 00782 Firm's EIN
Go to www.irs.gov/Form1040 for instructions and the latest information. US1040$2 Form 1040 (2023)
 OMB No. 1545-0121
Foreign Tax Credit
Form 1116 (Individual, Estate, or Trust) 2023
Department of the Treasury
Attach to Form 1040, 1040-SR, 1040-NR, 1041, or 990-T. Attachment
Internal Revenue Service Go to www.irs.gov/Form1116 for instructions and the latest information. Sequence No. 19
Name Identifying number as shown on page 1 of your tax return
ROBERTO NIEVES & VICTORIA MALDONADO 598-60-2066
Use a separate Form 1116 for each category of income listed below. See Categories of Income in the instructions. Check only one box on each
Form 1116. Report all amounts in U.S. dollars except where specified in Part II below.
a Section 951A category income c Passive category income e Section 901(j) income g Lump-sum distributions
b Foreign branch category income d X General category income f Certain income re-sourced by treaty

h Resident of (name of country) PUERTO RICO

Note: If you paid taxes to only one foreign country or U.S. possession, use column A in Part I and line A in Part II. If you paid taxes to
more than one foreign country or U.S. possession, use a separate column and line for each country or possession.
Part I Taxable Income or Loss From Sources Outside the United States (for category checked above)
Foreign Country or U.S. Possession Total
i Enter the name of the foreign country or U.S. A B C (Add cols. A, B, and C.)
possession . . . . . . . . . . . . . . . PUERTO RICO
1a Gross income from sources within country
shown above and of the type checked above (see
instructions):

WAGES 62,027 1a 62,027

b Check if line 1a is compensation for personal
services as an employee, your total
compensation from all sources is $250,000 or
more, and you used an alternative basis to
determine its source. See instructions . . .

Deductions and losses (Caution: See instructions.):

2 Expenses definitely related to the income on
line 1a (attach statement) . . . . . . . . . . .
3 Pro rata share of other deductions not definitely
related:
a Certain itemized deductions or standard
deduction (see instructions) . . . . . . . . . .
b Other deductions (attach statement) . . . . . .
c Add lines 3a and 3b . . . . . . . . . . . . .
d Gross foreign source income (see instructions) . . 62,027
e Gross income from all sources (see instructions) . . 62,027
f Divide line 3d by line 3e (see instructions) . . . . 1.0000
g Multiply line 3c by line 3f . . . . . . . . . . .
4 Pro rata share of interest expense (see instructions):
a Home mortgage interest (use the Worksheet for
Home Mortgage Interest in the instructions) . . . .
b Other interest expense. . . . . . . . . . . . .
5 Losses from foreign sources . . . . . . . . .
6 Add lines 2, 3g, 4a, 4b, and 5 . . . . . . . . . 6
7 Subtract line 6 from line 1a. Enter the result here and on line 15, page 2 . . . . . . . . . . . . . . . . . 7 62,027
Part II Foreign Taxes Paid or Accrued (see instructions)
Credit is claimed
for taxes (you Foreign taxes paid or accrued
must check one)
(j) Paid In foreign currency In U.S. dollars

(k) X Accrued Taxes withheld at source on: (p) Other Taxes withheld at source on: (t) Other (u) Total foreign
foreign taxes foreign taxes taxes paid or
(l) Date paid (n) Rents paid or (r) Rents paid or accrued (add cols.
(m) Dividends (o) Interest (q) Dividends (s) Interest
or accrued and royalties accrued and royalties accrued (q) through (t))
A 12/31/2023 3,657 3,657
B
C
8 Add lines A through C, column (u). Enter the total here and on line 9, page 2 . . . . . . . . . . . . . . 8 3,657
For Paperwork Reduction Act Notice, see instructions. Form 1116 (2023)
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Form 1116 (2023) ROBERTO NIEVES & VICTORIA MALDONADO 598-60-2066 Page 2
Part III Figuring the Credit
9 Enter the amount from line 8. These are your total foreign taxes paid or
accrued for the category of income checked above Part I . . . . . . . . . . . . 9 3,657
10 Enter the sum of any carryover of foreign taxes (from Schedule B,
line 3, column (xiv)) plus any carrybacks to the current tax year. If
you enter an amount on line 10 and you don't need to attach
Schedule B, check here (see instructions) . . . . . . . . . . . . . . . 10
(If your income was section 951A category income (box a above
Part I), leave line 10 blank.)
11 Add lines 9 and 10 . . . . . . . . . . . . . . . . . . . . . . . . . . 11 3,657

12 Reduction in foreign taxes (see instructions) . . . . . . . . . . . . . . . . . 12

13 Taxes reclassified under high tax kickout (see instructions) . . . . . . . . . . . 13

14 Combine lines 11, 12, and 13. This is the total amount of foreign taxes available for credit . . . . . . . . . . . 14 3,657

15 Enter the amount from line 7. This is your taxable income or (loss) from
sources outside the United States (before adjustments) for the category
of income checked above Part I. See instructions . . . . . . . . . . . . . . . 15 62,027
16 Adjustments to line 15 (see instructions) . . . . . . . . . . . . . . . . . . 16

17 Combine the amounts on lines 15 and 16. This is your net foreign
source taxable income. (If the result is zero or less, you have no
foreign tax credit for the category of income you checked above
Part I. Skip lines 18 through 24. However, if you are filing more than
one Form 1116, you must complete line 20.) . . . . . . . . . . . . . . . . 17 62,027
18 Individuals: Enter the amount from line 15 of your Form 1040,
1040-SR, or 1040-NR. Estates and trusts: Enter your taxable
income without the deduction for your exemption . . . . . . . . . . . . . . . 18 34,327
Caution: If you figured your tax using the lower rates on qualified dividends or capital gains, see
instructions.
19 Divide line 17 by line 18. If line 17 is more than line 18, enter "1" . . . . . . . . . . . . . . . . . . . . 19 1.0000
20 Individuals: Enter the total of Form 1040, 1040-SR, or 1040-NR, line 16, and Schedule 2 (Form
1040), line 2. Estates and trusts: Enter the amount from Form 1041, Schedule G, line 1a; or the
total of Form 990-T, Part II, lines 2, 3, 4, and 6. Foreign estates and trusts should enter the amount
from Form 1040-NR, line 16. See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 3,679
Caution: If you are completing line 20 for separate category g (lump-sum distributions), or, if you file
Form 8978, Partner's Additional Reporting Year Tax, see instructions.

21 Multiply line 20 by line 19 (maximum amount of credit) . . . . . . . . . . . . . . . . . . . . . . . . 21 3,679

22 Increase in limitation (section 960(c)) (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . 22

23 Add lines 21 and 22 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 3,679

24 Enter the smaller of line 14 or line 23. If this is the only Form 1116 you are filing, skip lines 25
through 32 and enter this amount on line 33. Otherwise, complete the appropriate line in Part IV. See
instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 3,657
Part IV Summary of Credits From Separate Parts III (see instructions)
25 Credit for taxes on section 951A category income . . . . . . . . . . . . . . . 25
26 Credit for taxes on foreign branch category income . . . . . . . . . . . . . . 26
27 Credit for taxes on passive category income . . . . . . . . . . . . . . . . . 27
28 Credit for taxes on general category income . . . . . . . . . . . . . . . . . 28
29 Credit for taxes on section 901(j) income . . . . . . . . . . . . . . . . . . 29
30 Credit for taxes on certain income re-sourced by treaty . . . . . . . . . . . . . 30
31 Credit for taxes on lump-sum distributions . . . . . . . . . . . . . . . . . . 31
32 Add lines 25 through 31 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
33 Enter the smaller of line 20 or line 32 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 3,657
34 Reduction of credit for international boycott operations. See instructions for line 12 . . . . . . . . . . . . . 34
35 Subtract line 34 from line 33. This is your foreign tax credit. Enter here and on Schedule 3 (Form
1040), line 1; Form 1041, Schedule G, line 2a; or Form 990-T, Part III, line 1a . . . . . . . . . . . . . . 35 3,657
Form 1116 (2023)
 Paid Preparer's Due Diligence Checklist
Form 8867 Earned Income Credit (EIC), American Opportunity Tax Credit (AOTC),
Child Tax Credit (CTC) (including the Additional Child Tax Credit (ACTC) and
OMB No. 1545-0074
For tax year
20
(Rev. November 2023)
Credit for Other Dependents (ODC)), and Head of Household (HOH) Filing Status
To be completed by preparer and filed with Form 1040, 1040-SR, 1040-NR, 1040-PR, or 1040-SS. Attachment
Department of the Treasury
Internal Revenue Service Go to www.irs.gov/Form8867 for instructions and the latest information.
Sequence No. 70
Taxpayer name(s) shown on return Taxpayer identification number

ROBERTO NIEVES & VICTORIA MALDONADO 598-60-2066

Preparer's name Preparer tax identification number

ANGEL M CINTRON MORALES P01787029

Part I Due Diligence Requirements
Please check the appropriate box for the credit(s) and/or HOH filing status claimed on the return and complete the related Parts I–V
for the benefit(s) claimed (check all that apply). EIC X CTC/ACTC/ODC AOTC HOH
1 Did you complete the return based on information for the applicable tax year provided by the taxpayer Yes No N/A
or reasonably obtained by you? . . . . . . . . . . . . . . . . . . . . . . . . . . . . X
2 If credits are claimed on the return, did you complete the applicable EIC and/or CTC/ACTC/ODC
worksheets found in the Form 1040, 1040-SR, 1040-NR, 1040-PR, 1040-SS, or Schedule 8812 (Form
1040) instructions, and/or the AOTC worksheet found in the Form 8863 instructions, or your own
worksheet(s) that provides the same information, and all related forms and schedules for each credit
claimed? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X
3 Did you satisfy the knowledge requirement? To meet the knowledge requirement, you must do both
of the following.
• Interview the taxpayer, ask questions, and contemporaneously document the taxpayer's responses
to determine that the taxpayer is eligible to claim the credit(s) and/or HOH filing status.
• Review information to determine that the taxpayer is eligible to claim the credit(s) and/or HOH filing
status and to figure the amount(s) of any credit(s) . . . . . . . . . . . . . . . . . . . . X
4 Did any information provided by the taxpayer or a third party for use in preparing the return, or
information reasonably known to you, appear to be incorrect, incomplete, or inconsistent? (If "Yes,"
answer questions 4a and 4b. If "No," go to question 5.) . . . . . . . . . . . . . . . . . . X
a Did you make reasonable inquiries to determine the correct, complete, and consistent information? .
b Did you contemporaneously document your inquiries? (Documentation should include the questions
you asked, whom you asked, when you asked, the information that was provided, and the impact the
information had on your preparation of the return.) . . . . . . . . . . . . . . . . . . . .
5 Did you satisfy the record retention requirement? To meet the record retention requirement, you must
keep a copy of your documentation referenced in question 4b, a copy of this Form 8867, a copy of any
applicable worksheet(s), a record of how, when, and from whom the information used to prepare Form
8867 and any applicable worksheet(s) was obtained, and a copy of any document(s) provided by the
taxpayer that you relied on to determine eligibility for the credit(s) and/or HOH filing status or to figure
the amount(s) of the credit(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X
List those documents provided by the taxpayer, if any, that you relied on:
GOVERNMENT DOCS

6 Did you ask the taxpayer whether he/she could provide documentation to substantiate eligibility for the
credit(s) and/or HOH filing status and the amount(s) of any credit(s) claimed on the return if his/her
return is selected for audit? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X
7 Did you ask the taxpayer if any of these credits were disallowed or reduced in a previous year? . . . X
(If credits were disallowed or reduced, go to question 7a; if not, go to question 8.)
a Did you complete the required recertification Form 8862? . . . . . . . . . . . . . . . . . .
8 If the taxpayer is reporting self-employment income, did you ask questions to prepare a complete and
correct Schedule C (Form 1040)? . . . . . . . . . . . . . . . . . . . . . . . . . . . X
For Paperwork Reduction Act Notice, see separate instructions. Form 8867 (Rev. 11-2023)
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Form 8867 (Rev. 11-2023)
ROBERTO NIEVES & VICTORIA MALDONADO 598-60-2066 Page 2
Part II Due Diligence Questions for Returns Claiming EIC (If the return does not claim EIC, go to Part III.)
9a Have you determined that the taxpayer is eligible to claim the EIC for the number of qualifying children Yes No N/A
claimed, or is eligible to claim the EIC without a qualifying child? (If the taxpayer is claiming the EIC
and does not have a qualifying child, go to question 10.) . . . . . . . . . . . . . . . .
b Did you ask the taxpayer if the child lived with the taxpayer for over half of the year, even if the taxpayer
has supported the child the entire year? . . . . . . . . . . . . . . . . . . . . . . . . .
c Did you explain to the taxpayer the rules about claiming the EIC when a child is the qualifying child of
more than one person (tiebreaker rules)? . . . . . . . . . . . . . . . . . . . . . . . .
Part III Due Diligence Questions for Returns Claiming CTC/ACTC/ODC (If the return does not claim CTC, ACTC,
or ODC, go to Part IV.)
10 Have you determined that each qualifying person for the CTC/ACTC/ODC is the taxpayer's dependent Yes No N/A
who is a citizen, national, or resident of the United States? . . . . . . . . . . . . . . . . . X
11 Did you explain to the taxpayer that he/she may not claim the CTC/ACTC if the child has not lived with
the taxpayer for over half of the year, even if the taxpayer has supported the child, unless the child's
custodial parent has released a claim to exemption for the child? . . . . . . . . . . . . . . . X
12 Did you explain to the taxpayer the rules about claiming the CTC/ACTC/ODC for a child of divorced or
separated parents (or parents who live apart), including any requirement to attach a Form 8332 or
similar statement to the return? . . . . . . . . . . . . . . . . . . . . . . . . . . . . X
Part IV Due Diligence Questions for Returns Claiming AOTC (If the return does not claim AOTC, go to Part V.)
13 Did the taxpayer provide substantiation for the credit, such as a Form 1098-T and/or receipts for the qualified Yes No
tuition and related expenses for the claimed AOTC? . . . . . . . . . . . . . . . . . . . . . . . .
Part V Due Diligence Questions for Claiming HOH (If the return does not claim HOH filing status, go to Part VI.)
14 Have you determined that the taxpayer was unmarried or considered unmarried on the last day of the tax year Yes No
and provided more than half of the cost of keeping up a home for the year for a qualifying person? . . . . .
Part VI Eligibility Certification
You will have complied with all due diligence requirements for claiming the applicable credit(s) and/or HOH filing
status on the return of the taxpayer identified above if you:
A. Interview the taxpayer, ask adequate questions, contemporaneously document the taxpayer's responses on the return or
in your notes, review adequate information to determine if the taxpayer is eligible to claim the credit(s) and/or HOH filing
status and to figure the amount(s) of the credit(s);
B. Complete this Form 8867 truthfully and accurately and complete the actions described in this checklist for any applicable
credit(s) claimed and HOH filing status, if claimed;
C. Submit Form 8867 in the manner required; and
D. Keep all five of the following records for 3 years from the latest of the dates specified in the Form 8867 instructions
under Document Retention.
1. A copy of this Form 8867.
2. The applicable worksheet(s) or your own worksheet(s) for any credit(s) claimed.
3. Copies of any documents provided by the taxpayer on which you relied to determine the taxpayer's eligibility for the
credit(s) and/or HOH filing status and to figure the amount(s) of the credit(s).
4. A record of how, when, and from whom the information used to prepare this form and the applicable worksheet(s) was
obtained.
5. A record of any additional information you relied upon, including questions you asked and the taxpayer's responses, to
determine the taxpayer's eligibility for the credit(s) and/or HOH filing status and to figure the amount(s) of the credit(s).
If you have not complied with all due diligence requirements, you may have to pay a penalty for each failure to
comply related to a claim of an applicable credit or HOH filing status (see instructions for more information).

15 Do you certify that all of the answers on this Form 8867 are, to the best of your knowledge, true, correct, and Yes No
complete? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . X
Form 8867 (Rev. 11-2023)