STATE OF HAWAII — DEPARTMENT OF TAXATION
Dependent Care Provider’s Identification and Certification
(DO NOT file with your tax return. Keep for your records)
Part I — Dependent Care Provider’s Identification (See Instructions)
Name of dependent care provider
Provider’s taxpayer identification number
Address (number and street)
If the above number is a social security number,
check this box
City, State, and Postal/ZIP code
GE/Use I.D. No.
GE __ __ __-__ __ __-__ __ __ __ - __ __
Certification and Signature of Dependent Care Provider. Under penalties set forth in section 231-36, HRS, I as the dependent care provider, certify
that my name, address, taxpayer identification number, and general excise tax identification number, as shown above, are correct.
Signature of Dependent Care Provider
Part II — Name and Address of Taxpayer Requesting Part I Information (See Instructions)
Name, street address, City, State, and Postal/ZIP code of person requesting information
and a GE/Use I.D. No. below.
If the provider is exempt from federal income
You are required to get the information in Part I
You only need to complete this part if you give
tax as an organization described in IRC
from anyone who provides care for your child or
Form HW-16 to your provider and it is to be
section 501(c)(3), see If Provider Is an Exempt
other dependent if:
returned to you at some later time.
you intend to claim a tax credit on your tax return
How To Get a TIN and a GE/Use Tax I.D. No. —
for child and dependent care expenses; or
Providers who do not have a TIN or a GE/Use
If No Information Is Reported. — You will not be
I.D. No. should apply for one immediately. To
you receive benefits from a dependent
allowed the tax credit or the income exclusion for
apply for an SSN, they should get federal Form
care assistance program provided by your
employer-provided dependent care assistance if:
SS-5, Application for a Social Security Card (for
individuals), from their local office of the Social
you do not include the name, address, TIN, or
You must report the correct name, address,
Security Administration. To apply for an ITIN, they
GE/Use I.D. No. of the provider on your income
taxpayer identification number (TIN), and general
should get federal Form W-7, Application for IRS
tax return; and
excise tax identification number (GE/Use I.D.
Individual Taxpayer Identification Number, from
No.) of the dependent care provider (provider)
you cannot establish, to the Department upon
their local IRS office. To apply for a FEIN, they
on Schedule X, Tax Credits for Hawaii Residents.
its request, that you exercised due diligence in
should get federal Form SS-4, Application for
obtaining this information.
You may use Form HW-16 to get this information
Employer Identification Number (for businesses
from each provider or you may use any one of the
Due Diligence. — You can show that you
and other entities), from their local IRS office. To
other methods described under Due Diligence,
apply for a GE/Use I.D. No., they should get Form
below. A copy of federal Form W-10 may not be
BB-1, State of Hawaii Basic Business Application,
information by getting and keeping:
submitted for Form HW-16. Do not file Form HW-
from their respective district Department office.
a Form HW-16 properly completed by the
16 with your income tax return. Instead, keep it
Form BB-1 may also be obtained
for your records.
the Department at 808-587-4242 or toll-free
at 1-800-222-3229, or by downloading it from
a copy of the provider’s social security card
Section 235-55.6, Hawaii Revised Statutes
the Department’s website (tax.hawaii.gov).
and general excise tax license; or
(HRS), requires anyone providing dependent
NOTE: An ITIN is for tax use only. It does not
care services to you to give you this information.
a recently printed letterhead or printed invoice
entitle the individual to social security benefits or
The Department of Taxation (Department) uses
that has on it the provider’s name, address,
change employment or immigration status under
the TIN and GE/Use I.D. No. for identification
TIN, and GE/Use I.D. No.; or
purposes and to help verify the accuracy of the
where the employer is the provider, a copy
If Provider Is an Exempt Organization. — If the
provider’s return as well as your return. Providers
of the statement furnished by the employer
must give you their TIN and GE/Use I.D. No.
provider is a tax-exempt organization of the type
under a dependent care assistance program,
whether or not they are required to file a tax
described in IRC section 501(c)(3), the provider
showing the employer’s name, address, TIN
is not required to supply its TIN or GE/Use I.D.
and GE/Use I.D. No.; or
No. In such cases, the organization completes
where the provider is your household employee
the name and address part of Form HW-16
and has given you a properly completed Form
and writes “tax-exempt” in the space provided
The provider completes this part.
HW-4 to have income tax withheld, a copy of
for the TIN and GE/Use I.D. No.. Generally, the
The provider’s name, address, TIN, and GE/Use
type of exempt organization described in IRC
I.D. No. should be entered in the spaces above.
section 501(c)(3) is one organized and operated
If your provider does not comply with your request
exclusively for religious, charitable, scientific,
for one of these items, you must still furnish the
For individuals and sole proprietors, the TIN is a
testing for public safety, literary, or educational
name, address, and, if known, the TIN and GE/
social security number (SSN). But if the provider
purposes, or for the prevention of cruelty to
Use I.D. No. of the provider on Schedule X. Also,
is a nonresident or resident alien who does not
children or animals.
you should include a statement on Schedule X
have and is not eligible to get an SSN, the TIN
Income Tax Reporting Requirements for
that you requested the information and that the
is an Internal Revenue Service (IRS) individual
Providers. — The provider must report on his
provider did not comply with the request. This
taxpayer identification number (ITIN). For other
statement will show that you exercised due
entities, it is the federal employer identification
or her income tax return all income received for
diligence, unless you know that the statement is
number (FEIN). If the provider does not have a
providing care for any person.
TIN or a GE/Use I.D. No., see How to Get a TIN