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SWORN DECLARATION AND WAIVER OR RIGHT TO CLAIM

EXEMPTION OF DEPENDENT CHILDREN BY THE HUSBAND

In accordance with the provision of Section 29 (1) (2) (A) of the National Internal Revenue
Code, as amended, I ________________________, hereby voluntary depose and say:

1.That my wife and I are both income corners;


2.That we file a joint income tax returns on our taxable income;
3.That I hereby waive my right to claim the additional exemption for all our qualified
_______________________
(Number of Children)
dependent children in favor of my wife _____________________________ who is
(NAME)
presently employed with __________________________________, with office address at
____________________________________________________________________.

4.That this waiver shall be effective for the taxable year _________ and shall continue for
the
suceeding year /s unless sooner revoked.

I hereby declare under penalties of perjury that the foregoing representation are true and
correct and that the waiver of right is voluntarily and knowlingly made in accordance with the
provisions of the National Internal Revenue Code, as amended.

________________
Date

____________________
Taxpayer Signature

----------------------------------------------------------------------------------------------------------------------------- -----------------

This is to acknowledge receipt of the above waiver of Mr. __________________ in favor of his
wife ________________________ who shall be entitled to claim the additional exemption for all
their qualified dependent children effective _______________.
(Month)
__________________
Taxable year

______________________
Employer of Husband

Note: If husband is engaged in business disregard the acknowledgement receipt portion of this form.