To request this document in an alternate format, please complete the form dor.wa.gov/AccessibilityRequest or call 360-705-6705. Teletype (TTY) users please dial 711. REV 14 0001 (10/24/23) Applicant initials: _____________ Year of birth:___________ Page 1 of 6 Form 14 0001 Mail to: Washington State Dept. of Revenue Attn: Working Families Tax Credit Division PO Box 47468 Olympia, WA, 98504-7468 2023 Working Families Tax Credit Application Skip the paper form and file online! Go to WorkingFamiliesCredit.wa.gov Need help? Email DORWFTC@dor.wa.gov, call 360-763-7300, or read instructions at workingfamiliescredit.wa.gov/get-help. What is your preferred language for receiving communication? English Spanish Other The Department currently sends letters in English only. We are collecting other language preferences to determine which languages are needed in the future. Amended application? Check this box and attach a letter of explanation.

A. Your information 1. First name Middle initial Last name

2. Valid SSN or ITIN

I am currently waiting for an ITIN from the IRS (for myself, my spouse, and/or my child). 3. Date of birth (MM/DD/YYYY) 4. Washington state driver’s license or ID number

I do not have or do not want to provide a Washington State license or ID number. Note: Providing your license or ID number will generally expedite the application review process. 5. Mailing address City State Zip code 6. Primary phone Cell phone Email

B. Residency questions 7. Did you live in Washington for at least 183 days in 2023?

Yes No 8. Is your mailing address in Section A the same as your current primary residence?

Yes No If yes, skip to Section C. 9. If you answered “no” to question 8, what is your current primary residence? Address

City State Zip code

I do not have or do not want to provide an address for my primary residence. Note: Providing your address of primary residence will generally expedite the application review process and decrease the likelihood of additional contact from the Department.

Working Families Tax Credit Application REV 14 0001 (10/24/23) Applicant initials: _____________ Year of birth:___________ Page 2 of 6 C. Eligibility questions 10. What was your filing status for your 2023 federal tax return?

Single Head of household Qualifying Surviving Spouse

Married filing jointly Married filing separately 11. Did you claim the federal EITC in 2023? Yes No If yes, skip to question 13. 12. Did you meet all of the following criteria even though you didn’t claim the federal EITC in 2023? Yes No • You must meet the IRS Adjusted Gross Income (AGI) thresholds based on your tax filing status. View the AGI threshold brackets in the instructions. • If you (and your spouse if applicable) have no children, you (or your spouse) must be 25 - 64 years old at the end of 2023. • If you (or your spouse if applicable) have investment income, it must be less than $11,000. • The following situations do NOT apply to you (these are less common): օ You filed a Federal Form 2555, relating to foreign income. օ You (or your spouse if applicable) were claimed as a qualifying child of another person. օ If you do not have qualifying children, you (or your spouse if applicable) were claimed as a dependent of another person. օ You (or your spouse if applicable) were treated as a U.S. nonresident alien. օ You are currently in a disallowance period from claiming the Federal Earned Income Tax Credit (EITC). D. Spouse information If you do not have a spouse, skip to Section E. 13. First name Middle initial Last name 14. Valid SSN or ITIN

15. Date of birth (MM/DD/YYYY)

E. Information on qualifying children If you do not have qualifying children, skip to Section F. Instructions: Fill out the following information for each qualifying child. A qualifying child can only be claimed by one individual or couple. Review the instructions if you have questions about who you can claim the child. If a qualifying child was born and deceased in 2023, write “deceased” in the Valid SSN or ITIN field. A qualifying child must have one of the following relationships to the applicant: • Child – A child, stepchild, adopted child, foster child or descendant of one of these (for example, grandchild). • Sibling – A sibling, half-sibling, stepsibling or descendant of one of these (for example, niece or nephew).

Working Families Tax Credit Application REV 14 0001 (10/24/23) Applicant initials: _____________ Year of birth:___________ Page 3 of 6 16. Questions Child 1 Child 2 Child 3 First name Middle initial Last name Date of birth (MM/DD/YYYY) Valid SSN or ITIN Select the qualifying child’s relationship to you. Child, stepchild, adopted child, or foster child Sibling, half-sibling, or stepsibling Child, stepchild, adopted child, or foster child Sibling, half-sibling, or stepsibling Child, stepchild, adopted child, or foster child Sibling, half- sibling, or stepsibling Did this child live with you more than half the year? Yes No Yes No Yes No Was this child a student? Yes No Yes No Yes No Was this child permanently and totally disabled during any part of 2023? Yes No Yes No Yes No Did you claim this qualifying child for EITC on your federal tax return? Yes No Yes No Yes No F. Earned income Instructions: Provide income for 2023. Income information 17. Income reported on line 1z, Form 1040 or 1040-SR. 18. Adjusted Gross Income (AGI) reported on line 11, Form 1040 or 1040-SR. 19. Did you itemize your 2023 federal tax return?

Yes No Not sure

Refer to the instructions for information about how to determine if you itemized your tax return. 20. Did any of the following situations apply to you in 2023? If so, check all the boxes that apply.

Self-Employed (reported on Schedule C, Schedule F, and/or Schedule SE and Schedule E).

Member of a clergy or employed by a church and filed a Schedule SE.

Employed by the military and received combat pay reported on Form 1040 or 1040SR line 1i.

Statutory employee and filed a Schedule C with your federal tax return reported on Schedule C line 1.

Had a Medicaid waiver payment reported on Schedule 1 line 8s.

Working Families Tax Credit Application REV 14 0001 (10/24/23) Applicant initials: _____________ Year of birth:___________ Page 4 of 6 G. How would you like to receive your credit? Instructions: Select a method for receiving your credit. If you do not fill out this section, or the direct deposit information provided is invalid, we will send a check to your mailing address you provided in Section A. If you choose direct deposit, it is important your bank account information is accurate. Check with your financial institution to get the correct routing and account numbers to make sure your direct deposit will be accepted. Department of Revenue is not responsible for a lost payment if you enter the wrong account information. Direct deposit Bank routing number Account number

Type of account: Personal Checking Personal Savings

Business Checking Business Savings Mailed check (Make sure your address is correct in Section A Your information, page 1) Prepaid debit card • Prepaid debit cards will only be issued in the name of the primary applicant, and only one card will be issued. • The prepaid debit card will be sent to the mailing address you provided on this application. • Once a refund has been issued on a prepaid debit card, DOR will not be able to change your method of payment. Please ensure all information you have provided is accurate. • To learn more about the prepaid debit card terms and fees, please visit workingfamiliescredit.wa.gov/DebitCards. H. Attachments A copy of your 2023 federal tax return is required. This includes your federal form 1040 or 1040-SR and all forms and schedules submitted as part of your federal return. For example, if your tax return has any of the following, you must submit them with your application: • Schedule EIC • Schedule C • Schedule 1 • Schedule SE • Schedule E • Schedule F I. Declaration and signatures By signing this application, I agree to the following statements under penalties of perjury: • The information provided is true, correct, and complete. • I have documentation to support my responses on this application and can provide them to the department if requested. • I filed the federal income tax return included with this application with the Internal Revenue Service as of the date of signing. • This application is not filed on behalf of a deceased individual. • I have paid sales tax on purchases I made during the period for which the refund is being claimed. Applicant signature ________________________________ Date (MM/DD/YYYY) ____________ Spouse signature* ________________________________ Date (MM/DD/YYYY) ____________ *Required if filing as “married filing jointly.”

Working Families Tax Credit Application REV 14 0001 (10/24/23) Applicant initials: _____________ Year of birth:___________ Page 5 of 6 The Preparer information section (J.) and the Demographic information section (K.) are both voluntary. Completing or not completing these sections will not impact your eligibility for the refund. J. Preparer information 21. Did you prepare your own application? If no, please answer below.

Yes No a. Preparer’s name Phone

b. Preparer’s business name Email c. Preparer Tax Identification Number (PTIN): d. Was this application prepared at a Volunteer Income Tax Assistance (VITA) site?

Yes No If yes, VITA site name To authorize the Department of Revenue to speak with the preparer, a Confidential Tax Information Authorization form is required. You can find the form and attach with this application. K. Demographic information Purpose: Information collected from this application will help inform and improve the program. Your input will ensure that tax dollars are returned to working families like yours. Without your input, the Legislature may find it difficult to evaluate the program’s effectiveness. Your responses to the racial and ethnic background questions will not affect eligibility or benefit amounts. Select any combination. 22. Are you of Hispanic, Latino, or Spanish origin? Please check all that apply. Hispanic, Latino, or Spanish Origin You Spouse Child 1 Child 2 Child 3 No, not of Hispanic, Latino, or Spanish origin Yes, Mexican, Mexican- American, Chicano Yes, Central American (countries below Mexico and above South America) Yes, Caribbean Islands Yes, South American Yes, Indigenous Describe Describe Describe Describe Describe Yes, another Hispanic, Latino, or Spanish origin Describe Describe Describe Describe Describe Prefer not to say

Working Families Tax Credit Application REV 14 0001 (10/24/23) Applicant initials: _____________ Year of birth:___________ Page 6 of 6 23. What race do you consider yourself? Please check all that apply. Race You Spouse Child 1 Child 2 Child 3 American Indian or Alaskan Native Tribe name Tribe name Tribe name Tribe name Tribe name Amhara Asian Indian

Black or African American Chamorro Chinese Eritrean Filipino Japanese Korean Native Hawaiian Oromo Samoan Somali Tigre Vietnamese Western African White Other African Describe Describe Describe Describe Describe Other Asian Describe Describe Describe Describe Describe Other Pacific Islander Describe Describe Describe Describe Describe Other race Describe Describe Describe Describe Describe Prefer not to say 24. How did you hear about the Working Families Tax Credit program? Website Social Media Another organization or agency Word of mouth Other