Form N-11/n-12/n-13/n-15 - Schedule X - Tax Credits For Hawaii Residents - 2001 Page 2
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2Schedule X (Form N-11/N-12/N-13/N-15) (Rev. 2001)
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PART III: CREDIT FOR CHILD AND DEPENDENT CARE EXPENSES
Section A: Care Provider Information
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(a) Care
(b) Address
(c) Identification number
(d) General Excise
(e) Amount paid
Provider’s name
(number, street, city, state and ZIP code)
(SSN or EIN)
Tax License Number
Section B: Employer-Paid Dependent Care Benefits
— (If you did not receive benefits, skip to line 16)
2 If you filed a federal dependent care expense form, enter the amount from line 10 of either federal Form 2441 or
Schedule 2 of federal Form 1040A and skip to line 11 below. Otherwise, enter the total amount of dependent care
benefits you received from your employer for 2001. This amount should be in Box 10 of your W-2 form(s) ..............
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3 Enter the amount forfeited, if any. (See the Instructions) ............................................................................................
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4 Line 2 minus line 3........................................................................................................................................................
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5 Enter the total amount of qualified expenses incurred in 2001 for the care of the qualifying person(s) ........
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6 Enter the smaller of line 4 or 5 ......................................................................................
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7 Enter YOUR earned income.........................................................................................
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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 ...........................................................
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9 Enter the smallest of line 6, 7, or 8................................................................................
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10 Excluded benefits. Enter here the smaller of the following: (a) the amount from line 9, or (b) $5,000 ($2,500 if
married filing a separate return and you were required to enter your spouse’s earned income on line 8). ..................
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11 Taxable benefits. If you filed federal Form 2441 or Schedule 2 of federal Form 1040A, enter the amount from line
19 of that federal form and skip to line 20 below. Otherwise, enter the result of line 4 minus line 10. 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" .....
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12 Enter $2,400 ($4,800 if two or more qualifying persons).................................................
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13 Enter the amount from line 10........................................................................................
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14 Line 12 minus line 13. If zero or less, STOP. You cannot take the credit. Exception. If you paid 2000
expenses in 2001 (see Instructions) .............................................................................................................................
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15 Enter the amount of qualified expenses you incurred and paid in 2001. DO NOT include on this line any
excluded benefits shown on line 10..............................................................................................................................
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Section C: Credit for Child and Dependent Care Expenses
(d) Qualified expenses
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(a) Qualifying person’s name
(b) Relationship
(c) Qualifying person’s social
you incurred and paid
security number
in 2001 for the person
listed in column (a)
17 Add the amounts in column (d) of line 16. 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 14 or line 15..............................................................................
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18 Enter YOUR earned income.........................................................................................
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19 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 18 .......................
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20 If you filed federal Form 2441 or Schedule 2 of federal Form 1040A, enter the amount
from line 6 of that federal form. Otherwise, enter the smallest of line 17, 18, or 19........................................................
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21 Enter adjusted gross income from Form N-11, line 19; Form N-12, line 32;
Form N-13, line 11; or Form N-15, line 33, Column A.....................................................
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22 Enter on line 22 the decimal amount shown below that applies to the amount on line 21.
If line 21 is:
Decimal amount is:
If line 21 is:
Decimal amount is:
$0 — 22,000
.25
$32,001 — 34,000
.19
22,001 — 24,000
.24
34,001 — 36,000
.18
24,001 — 26,000
.23
36,001 — 38,000
.17
26,001 — 28,000
.22
38,001 — 40,000
.16
28,001 — 30,000
.21
40,001 and over
.15
30,001 — 32,000
.20
.........................................
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X
23 Multiply line 20 by the decimal amount on line 22. Enter the result here and on Form N-11, line 35;
00
Form N-12, line 48; Form N-13, line 19e; or Form N-15, line 50. (Whole dollars only).................................................
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