California Form 3506 - Child And Dependent Care Expenses Credit - 2010
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1
2CALIFORNIA FORM
TAXABLE YEAR
3506
2010
Child and Dependent Care Expenses Credit
Attach to your California Form 540, 540A, or Long Form 540NR.
Name(s) as shown on return
SSN or ITIN
-
-
Part I
Unearned Income and Other Funds Received in 200. See instructions.
SOURCE OF INCOME/FUNDS
AMOUNT
SOURCE OF INCOME/FUNDS
AMOUNT
Part II Persons or Organizations Who Provided the Care in California – You must complete this part. See instructions.
Enter the following information for each person or organization that provided care in California. Only care provided in California qualifies for the credit.
If you need more space, attach a separate sheet.
Provider
Provider
a. Care provider’s name
b. Care provider’s address
(number, street, apt. no., city, state,
and ZIP Code)
c. Care provider’s telephone number
(
)
(
)
d. Is provider a person or organization?
Person
Organization
Person
Organization
e. Identification number (SSN, ITIN, or FEIN)
f. Address where care was provided
(number, street, apt. no., city, state, and
ZIP Code) PO Box not acceptable.
g. Amount paid for care provided
Did you receive dependent care benefits?
No. Complete Part III below.
Yes. Complete Part IV on Side 2 before you complete Part III.
Part III Credit for Child and Dependent Care Expenses
2 Information about your qualifying person(s). See instructions.
(a)
(b)
(c)
(d)
(e)
Qualifying person’s name
Qualifying person’s
Qualifying person’s
Percentage of
Qualified expenses you
social security number (SSN)
date of birth
physical custody
incurred and paid in 2010 for
(See instructions)
(DOB – mm/dd/yyyy)
(See instructions)
the qualifying person’s
First
Last
or if disabled
care in California
DOB:_____________
Disabled Yes
DOB:_____________
Disabled Yes
DOB:_____________
Disabled Yes
3 Add the amounts in column (e) of line 2. Do not enter more than $3,000 for one qualifying person or $6,000 for two
or more qualifying persons. If you completed Side 2, Part IV, enter the amount from line 33 . . . . . . . . . . . . . . . . . . . . . .
3
00
4 Enter YOUR earned income. See instructions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4
00
Nonresidents: Enter only your earned income from California sources. If you do not have earned income from
California sources, stop, you do not qualify for the credit. Military servicemembers, see instructions.
Part-year residents: Enter the total of (1) your earned income from California sources received while you were a
nonresident and (2) all earned income received while you were a resident. Military servicemembers, see instructions.
5
f married or an RDP filing a joint return, enter YOUR SPOUSE’S/RDP’s earned income. (If your spouse/RDP was a
I
student or was disabled, see the instructions.) If not filing a joint return, enter the amount from line 4 . . . . . . . . . . . . . .
5
00
Nonresidents: Enter only your spouse’s/RDP’s earned income from California sources. If your spouse/RDP does not have
earned income from California sources, stop, you do not qualify for the credit. Military servicemembers, see line 4 instructions.
Part-year residents: Enter the total of (1) your spouse’s/RDP’s earned income from California sources received while he or
she was a nonresident and (2) all earned income your spouse/RDP received while he or she was a resident. Military
servicemembers, see line 4 instructions.
6 Enter the smallest of line 3, line 4, or line 5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6
00
X. ___ ___
7 Enter the decimal amount shown in the chart on page 4 of the instructions for line 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7
8 Multiply line 6 by the decimal amount on line 7. Enter the amount here and on Form 540/540A; line 77;
or Long Form 540NR, line 87. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8
00
X. ___ ___
9 Enter the decimal amount listed in the chart on page 4 of the instructions for line 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9
0 Multiply the amount on line 8 by the decimal amount on line 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
0
00
Credit for prior year expenses paid in 2010. See instructions for line 11 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
00
2 Add line 10 and line 11. Enter the amount here and on Form 540/540A, line 78; or Long Form 540NR, line 88 . . . . . . . . . . . .
2
00
FTB 3506 2010 Side
7251103
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