Form W-10 - Dependent Care Provider'S Identification And Certification - 1994


Dependent Care Provider’s Identification and Certification
(Rev. August 1994)
Do NOT file Form W-10 with your tax return. Instead, keep it for your records.
Department of the Treasury
Internal Revenue Service
Part I
Dependent Care Provider’s Identification (See instructions.)
Name of dependent care provider
Provider’s taxpayer identification number
Address (number, street, and apt. no.)
If the above number is a social security
number, check here
City, state, and ZIP code
Certification and Signature of Dependent Care Provider.—Under penalties of perjury, I, as the dependent care provider, certify
that my name, address, and taxpayer identification number shown above are correct.
Dependent care provider’s signature
Part II
Name and Address of Person Requesting Part I Information (See instructions.)
Name, street address, apt. no., city, state, and ZIP code of person requesting information
General Instructions
If the provider is your household employee and he or she gave
you a properly completed Form W-4, Employee’s Withholding
Section references are to the Internal Revenue Code.
Allowance Certificate, to have income tax withheld, a copy of
that Form W-4.
Purpose of form.—You must get the information shown in
Part I from each person or organization that provides care for
If your care provider does not comply with your request for
one of these items, you must still report certain information on
your child or other dependent if:
your Form 2441 or Schedule 2, whichever applies. For details,
1. You plan to claim a credit for child and dependent care
see the Form 2441 or Schedule 2 instructions.
expenses on Form 1040 or 1040A, or
2. You receive benefits under your employer’s dependent care
Specific Instructions
Part I
If either 1 or 2 above applies, you must show the correct
name, address, and taxpayer identification number (TIN) of each
The individual or organization providing the care completes this
care provider on Form 2441, Child and Dependent Care
Expenses, or Schedule 2, Child and Dependent Care Expenses
Enter the provider’s name, address, and TIN. For individuals
for Form 1040A Filers, whichever applies.
and sole proprietors, the TIN is a social security number. For
You may use Form W-10 or any of the other sources listed
other entities, it is the employer identification number. If the
under Due diligence below to get this information from each
provider is exempt from Federal income tax as an organization
described in section 501(c)(3), see Tax-exempt dependent care
Penalty for failure to furnish TIN.—TINs are needed to carry
provider below.
out the Internal Revenue laws of the United States. Section
How to get a TIN.—Providers who do not have a TIN should
6109(a) requires the providers of your dependent care services
apply for one immediately. To apply, individuals and sole
to give you their TIN even if they are not required to file a return.
proprietors should get Form SS-5, Application for a Social
The IRS uses the TIN to identify the provider and verify the
Security Card, from their local Social Security Administration
accuracy of the provider’s return as well as yours.
office. Other entities should get Form SS-4, Application for
A care provider who does not give you his or her correct TIN
Employer Identification Number, from their local IRS office.
is subject to a penalty of $50 for each failure unless the failure is
Tax-exempt dependent care provider.—A provider who is a
due to reasonable cause and not willful neglect. This penalty
tax-exempt organization described in section 501(c)(3) and
does not apply to an organization described in section 501(c)(3).
exempt under section 501(a) is not required to supply its TIN.
See Tax-exempt dependent care provider later.
Instead, the provider must complete the name and address lines
If incorrect information is reported.—You will not be allowed
and write "tax-exempt" in the space for the TIN. Generally, an
the tax credit or the exclusion for employer-provided dependent
exempt 501(c)(3) organization is one organized and operated
care benefits if:
exclusively for religious, charitable, scientific, testing for public
You report an incorrect name, address, or TIN of the provider
safety, literary, or educational purposes, or for the prevention of
cruelty to children or animals.
on your Form 2441 or Schedule 2, and
Income tax reporting requirements for dependent care
You cannot establish, to the IRS upon its request, that you
providers.—The individual provider must report on his or her
used due diligence in trying to get the required information.
income tax return all income received for providing care for any
Due diligence.—You can show due diligence by getting and
person. If the provider is a self-employed individual, the income
keeping in your records any one of the following:
is reported on Schedule C or C-EZ (Form 1040), whichever
A Form W-10 properly completed by the provider.
A copy of the provider’s social security card or driver’s license
Part II
(in a state where the license includes the social security
Complete this part only if your care provider will return the form
A recently printed letterhead or printed invoice that shows the
to you later.
provider’s name, address, and TIN.
If the provider is your employer’s dependent care plan, a copy
of the statement provided by your employer under the plan.
Cat. No. 10437N
(Rev. 8-94)
Printed on recycled paper


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