Form 2441n - Nebraska Child And Dependent Care Expenses - 2012
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Nebraska Child and Dependent Care Expenses
FORM 2441N
• File Form 2441N ONLY if your adjusted gross income is $29,000 or less, and you are claiming the
2012
Nebraska refundable child and dependent care credit.
• Complete the reverse side of this form if you received dependent care benefits.
• Attach this form to Form 1040N.
Name on Form 1040N
Your Social Security Number
BEFORE YOU BEGIN – Please see
Federal Form 2441
instructions for definitions of the following terms:
• Dependent Care Benefits
• Qualifying Persons
• Qualified Expenses
PART I — Persons or Organizations Who Provide the Care
• You must complete this part. (Paper filers, please attach a schedule if you need more space.)
(D)
1
(A)
(B)
(C)
Amount Paid
Care
Address
Identifying Number
(See Federal Form 2441
Provider’s Name
(Number, Street, Apt. No., City, State, and Zip Code)
(SSN or EIN)
instructions)
No
Complete only Part II below.
Did you receive
dependent care benefits?
Yes
Complete Part III on the back first, and then complete Part II.
CAUTION: If the care was provided in your home, you may owe employment taxes. See Federal Form 1040 instructions, line 59a.
PART II — Credit for Child and Dependent Care Expenses
2 Information about your qualifying persons.
(Paper filers, please attach a schedule if you have more than three qualifying persons.)
(A)
(B)
(C) Qualified Expenses You
Qualifying Person’s Name
Qualifying Person’s
Incurred and Paid in 2012 for the
First
Last
Social Security Number
Persons Listed in Column (A)
3 Add the amounts in Column (C) of line 2. Do not enter more than $3,000 for one qualifying person,
or $6,000 for two or more persons. If you completed Part III, enter the amount from line 34 . . . . . .
3
4 Enter your earned income (see Federal Form 2441 instructions) . . . . . . . . . . . . . . . . . . . . . . . . . .
4
5 If married, filing jointly, enter your spouse’s earned income. If your spouse was a student or was
disabled, see Federal Form 2441 instructions; all others, enter the amount from line 4 . . . . . . . . .
5
6 Enter the smallest of line 3, 4, or 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6
7 Enter the amount from Nebraska Form 1040N, line 5. (If line 7 is over
$29,000, do not file this form; instead see instructions for line 24,
Form 1040N, and use Federal Form 2441.) . . . . . . . . . . . . . . . . . . . . . . . .
7
8 Enter the federal decimal amount shown below that applies to the dollar amount on line 7.
If line 7 is:
If line 7 is:
But not
Federal decimal
But not
Federal decimal
Over
over
amount is
Over
over
amount is
$
0
–
15,000
.35
$21,000
–
23,000
.31
15,000
–
17,000
.34
23,000
–
25,000
.30
17,000
–
19,000
.33
25,000
–
27,000
.29
8
19,000
–
21,000
.32
27,000
–
29,000
.28
.
9 Enter the state decimal amount below that applies to the dollar amount on line 7.
If line 7 is:
If line 7 is:
But
State decimal
But
State decimal
Over
not over
amount is
Over
not over
amount is
$0 or less –
22,000
1.00
$25,000
–
26,000
.60
22,000
–
23,000
.90
26,000
–
27,000
.50
23,000
–
24,000
.80
27,000
–
28,000
.40
9
.
24,000
–
25,000
.70
28,000
–
29,000
.30
10 Multiply line 6 by the decimal amount on line 8 and enter result. If you paid 2011 expenses in 2012,
see Federal Form 2441 instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
11 Multiply line 10 by the decimal amount on line 9. Residents enter result here and on line 31, Form 1040N 11
12 Partial-year residents multiply line 11 by the ratio from Schedule III, line 67:______. Enter this
result here and on line 31, Form 1040N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
13 Part III, dependent care benefits, continued on next page
8-618-2012
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