Child And Dependent Care Expenses (Form 2441)
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1ORGANIZER
2014
1040
US
Child and Dependent Care Expenses (Form 2441)
33.1,33.2
Please enter all pertinent 2014 information. Last year's amounts are provided for your reference. You must have
paid for the care of one or more dependents enabling you to work or attend school to qualify for this credit.
2014 Amount
2013 Amount
DEPENDENT CARE EXPENSES (33.1)
Taxpayer
Spouse
Taxpayer
Spouse
Dependent care expenses incurred but not paid in 2014
3
53
. . .
Employer-provided benefits forfeited in 2014
6
56
. . . . . . . . . . . . . .
PERSONS AND EXPENSES QUALIFYING FOR DEPENDENT CARE CREDIT
First name
17
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Last name
18
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Title or suffix
24
. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Date of birth (m/d/y)
22
. . . . . . . . . . . . . . . . . . . . . .
No.
Social security number
19
. . . . . . . . . . . . . . . . . . . .
Qualified dependent care expenses
incurred and paid in 2014
20
2013 amt:
. . . . . . . . . . . . . . . . .
1=disabled
23
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1=spouse, 2=joint
21
. . . . . . . . . . . . . . . . . . . . . . . .
First name
17
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Last name
18
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Title or suffix
24
. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Date of birth (m/d/y)
22
. . . . . . . . . . . . . . . . . . . . . .
No.
Social security number
19
. . . . . . . . . . . . . . . . . . . .
Qualified dependent care expenses
incurred and paid in 2014
20
2013 amt:
. . . . . . . . . . . . . . . . .
1=disabled
23
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1=spouse, 2=joint
21
. . . . . . . . . . . . . . . . . . . . . . . .
PERSONS OR ORGANIZATIONS PROVIDING CARE (33.2)
Name of provider
10
. . . . . . . . . . . . . . . . . . . . . . . . .
Street address
11
. . . . . . . . . . . . . . . . . . . . . . . . . . .
City
12
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
State
26
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ZIP code
27
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
No.
Foreign region
28
. . . . . . . . . . . . . . . . . . . . . . . . . . . .
Foreign postal code
29
. . . . . . . . . . . . . . . . . . . . . . .
Foreign country
30
. . . . . . . . . . . . . . . . . . . . . . . . . .
Identification number (SSN or EIN)
13
. . . . . . . .
Amount paid to care provider in 2014
14
2013 amt:
. . . . . .
1=spouse, 2=joint
15
. . . . . . . . . . . . . . . . . . . . . . . .
33.1,33.2
Child and Dependent Care Expenses (Form 2441)
Series: 31, 34
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