Form N-11/n-12/n-13/n-15 - Schedule X - Tax Credits For Hawaii Residents - 2005 Page 2

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Schedule X (Form N-11/N-12/N-13/N-15) (Rev. 2005)

Page 2

PART III: CREDIT FOR CHILD AND DEPENDENT CARE EXPENSES

Section A: Care Provider Information

(a) Care

(b) Address

(d) Hawaii Tax

(e) Amount paid

Provider’s name

(number, street, city, state and ZIP code)

(SSN or FEIN)

I.D. Number

W __ __ __ __ __ __ __ __ - __ __

Section B: Dependent Care Benefits

— (If you did not receive benefits, skip to line 15)

2 Enter the total amount of dependent care benefits you received in 2005. Amounts you received as an employee

should be shown in Box 10 of your W-2 form(s). If you were self-employed or a partner, include amounts you

received under a dependent care assistance program from your sole proprietorship or partnership...........................

3 Enter the amount forfeited, if any. (See the Instructions) ............................................................................................

4 Line 2 minus line 3 .......................................................................................................................................................

5 Enter the total amount of qualified expenses incurred in 2005 for the care of the qualifying person(s) .........

6 Enter the smaller of line 4 or 5.......................................................................................

7 Enter YOUR earned income.........................................................................................

8 If married filing a joint return, enter YOUR SPOUSE’S earned income (if student or

disabled, see Instructions); if married filing separately, see the Instructions for the amount

to enter; all others, enter the amount from line 7 ...........................................................

9 Enter the smallest of line 6, 7, or 8 ................................................................................

10 Taxable benefits. Enter the amount of taxable benefits from the worksheet in the Instructions. Also, include this

amount on Form N-12, line 7; Form N-13, line 7; or Form N-15, line 7. On the corresponding dotted line write “DCB”.

11 Enter $2,400 ($4,800 if two or more qualifying persons) .................................................

12 Add lines f and i from the Taxable Benefits worksheet in the Instructions........................

13 Line 11 minus line 12. If zero or less, STOP. You cannot take the credit. Exception. If you paid 2004

expenses in 2005 (see Instructions).............................................................................................................................

14 Complete line 15. Do not include in column (d) any benefits shown on line 12. Then, add the amounts in column (d)

and enter the total here. ...............................................................................................................................................

Section C: Credit for Child and Dependent Care Expenses

— (If you are married, you must file a joint return to claim the tax credit.)

(d) Qualified expenses

(a) Qualifying person’s name

(b) Relationship

you incurred and paid

security number

in 2005 for the person

listed in column (a)

16 Add the amounts in column (d) of line 15. DO NOT enter more than $2,400 for one

qualifying person or $4,800 for two or more persons. If you completed Section B,

enter the smaller of line 13 or line 14..............................................................................

17 Enter YOUR earned income.........................................................................................

18 If married filing a joint return, enter YOUR SPOUSE’S earned income (if student or

disabled, see the Instructions); all others, enter the amount from line 17 .......................

19 Enter the smallest of line 16, 17, or 18........................................................................................................................

20 Enter adjusted gross income from Form N-11, line 20; Form N-12, line 35;

Form N-13, line 11; or Form N-15, line 36, Column A .....................................................

21 Enter on line 21 the decimal amount shown below that applies to the amount on line 20.

If line 20 is:

Decimal amount is:

If line 20 is:

Decimal amount is:

Under $22,001

.25

$32,001 — 34,000

.19

$22,001 — 24,000