Form 3506 - Child And Dependent Care Expenses Credit - 2003
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CALIFORNIA FORM
Child and Dependent Care Expenses Credit
2003
3506
Attach to your California Form 540, 540A, or Long Form 540NR.
Name(s) as shown on return
Social Security Number
-
-
Part I
Unearned Income and Other Funds Received in 2003. See instructions
SOURCE OF INCOME/FUNDS
AMOUNT
SOURCE OF INCOME/FUNDS
AMOUNT
Part II Persons or Organizations Who Provided the Care – You must complete this part. (If you need more space, attach a separate sheet.)
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(a)
(b)
(c)
(d)
(e)
Care provider’s name
Address (number, street, apt. no.,
Identifying
Telephone
Amount paid
Also check if provider is a person
city, state, and ZIP Code)
number (SSN or EIN)
number
(See instructions)
or an organization
Person
Organization
(
)
Person
Organization
(
)
No Complete Part III below.
Did you receive dependent care benefits?
Yes Complete Part V before 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
date of birth (DOB)
time spent in
incurred and paid in 2003
(See instructions)
or if disabled
your home
for the qualifying
First
Last
person’s care
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 Part V, enter the amount from line 30 . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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4 Enter YOUR earned income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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5 If married filing a joint return, enter YOUR SPOUSE’S earned income (if your spouse was a student or was
disabled, see the instructions); all others, enter the amount from line 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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6 Enter the smallest of line 3, line 4, or line 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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7 Enter the decimal amount shown in the chart on page 3 of the instructions for line 7 . . . . . . . . . . . . . . . . . . . . . . . . . . .
7
X.
8 Multiply line 6 by the decimal amount on line 7. Enter the amount here and on Form 540A, line 30;
Form 540, line 44; or Long Form 540NR, line 53 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8
9 Enter the decimal amount listed on the chart on page 3 of the instructions for line 9 . . . . . . . . . . . . . . . . . . . . . . . . . . .
9
X.
10 Multiply the amount on line 8 by the decimal amount on line 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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11 Credit for prior year expenses paid in 2003. See instructions for line 11 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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12 Add line 10 and line 11. Enter the amount here and on Form 540A, line 31, or Form 540, line 45.
Long Form 540NR filers enter the amount here and continue to Part IV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Part IV Nonresident and Part-Year Residents
13 Did you maintain your primary home in California for yourself and the qualifying person(s) during 2003?
Yes
No
(See instructions) If “Yes” continue. If “No,” stop. You do not qualify for the credit . . . . . . . . . . . . . . . . . . . . . . . . . . . .
13
X
14 Enter the percentage from Long Form 540NR, line 25a. (If your percentage is more than 1.00, enter 1.0000) . . . . . . . .
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___ . ___ ___ ___ ___
15 Multiply line 12 by line 14. Enter here and on Long Form 540NR, line 54 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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FTB 3506 2003 Side 1
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