Form 1npr Draft - Nonresident & Part-Year Resident Wisconsin Income Tax - 2012 Page 11
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182441
OMB No. 1545-0074
1040
Child and Dependent Care Expenses
. . . . . . . . . .
Form
1040A
2012
. . . . . . . . . .
Attach to Form 1040, Form 1040A, or Form 1040NR.
1040NR
2441
Department of the Treasury
Information about Form 2441 and its separate instructions is at
Attachment
21
Internal Revenue Service (99)
Sequence No.
Your social security number
Name(s) shown on return
Mary N. Sorrel
400-00-5413
DRAFT AS OF
Part I
Persons or Organizations Who Provided the Care—You must complete this part.
(If you have more than two care providers, see the instructions.)
1
(a) Care provider’s
(b) Address
(c) Identifying number
(d) Amount paid
name
(number, street, apt. no., city, state, and ZIP code)
(SSN or EIN)
(see instructions)
789 ABC Place
Learning Land, LLC
Sparta, WI 54656
39-2233445
1,200
August 8, 2012
No
Complete only Part II below.
Did you receive
dependent care benefits?
Yes
Complete Part III on the back next.
Caution. If the care was provided in your home, you may owe employment taxes. If you do, you cannot file Form 1040A. For details,
see the instructions for Form 1040, line 59a, or Form 1040NR, line 58a.
Part II
Credit for Child and Dependent Care Expenses
DO NOT FILE
2
Information about your qualifying person(s). If you have more than two qualifying persons, see the instructions.
(c) Qualified expenses you
(b) Qualifying person’s social
(a) Qualifying person’s name
incurred and paid in 2012 for the
security number
Last
person listed in column (a)
First
Sunny
Sorrel
400-00-5443
1,200
Add the amounts in column (c) of line 2. Do not enter more than $3,000 for one qualifying
3
person or $6,000 for two or more persons. If you completed Part III, enter the amount
from line 31 .
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1,200
3
20,000
4
Enter your earned income. See instructions
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4
5
If married filing jointly, 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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20,000
5
1,200
6
Enter the smallest of line 3, 4, or 5
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6
7
Enter the amount from Form 1040, line 38; Form
1040A, line 22; or Form 1040NR, line 37.
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20,000
7
8
Enter on line 8 the decimal amount shown below that applies to the amount on line 7
If line 7 is:
If line 7 is:
But not
Decimal
But not
Decimal
Over
over
amount is
Over
over
amount is
$0—15,000
.35
$29,000—31,000
.27
15,000—17,000
.34
31,000—33,000
.26
32
X
8
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17,000—19,000
.33
33,000—35,000
.25
19,000—21,000
.32
35,000—37,000
.24
21,000—23,000
.31
37,000—39,000
.23
23,000—25,000
.30
39,000—41,000
.22
25,000—27,000
.29
41,000—43,000
.21
27,000—29,000
.28
43,000—No limit
.20
9
Multiply line 6 by the decimal amount on line 8. If you paid 2011 expenses in 2012, see
the instructions .
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384
9
10
Tax liability limit. Enter the amount from the Credit
Limit Worksheet in the instructions.
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373
10
11
Credit for child and dependent care expenses. Enter the smaller of line 9 or line 10
here and on Form 1040, line 48; Form 1040A, line 29; or Form 1040NR, line 46 .
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373
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2441
For Paperwork Reduction Act Notice, see your tax return instructions.
Form
(2012)
Cat. No. 11862M
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