Form 2441n - Nebraska Child And Dependent Care Expenses - 2012 Page 2
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2FORM 2441N
Dependent Care Benefits
2012
Name as Shown on Form 1040N
Social Security Number
PART III — Dependent Care Benefits
14 Enter the total amount of dependent care benefits you received in 2012. Amounts you
received as an employee should be shown in box 10 of your Federal Form W-2. Do not include
amounts reported as wages in box 1 of Form W-2. If you were self-employed or a partner in a
partnership, include amounts you received under a dependent care assistance program from your
sole proprietorship or partnership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
15 Enter the amount forfeited or carried forward to 2013, if any (see Federal Form 2441 instructions) . . . 15
16 Subtract line 15 from line 14 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
17 Enter the total amount of qualified expenses incurred in 2012 for the care
of the qualifying persons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
18 Enter the smaller of line 16 or 17 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
19 Enter your earned income (see Federal Form 2441 instructions) . . . . . . . . . 19
20 Enter the amount shown below that applies to you:
• If married, filing jointly, enter your spouse’s earned income (If your spouse
was a student or was disabled, see Federal Form 2441 instructions, line 5);
• If married, filing separately, see Federal Form 2441 instructions for the
amount to enter; or
• All others, enter the amount from line 19 . . . . . . . . . . . . . . . . . . . . . . . . . . 20
21 Enter the smallest of line 18, 19, or 20 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
22 Enter the amount from line 14 that you received from your sole proprietorship or partnership.
If you did not receive any such amounts, enter -0- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
23 Subtract line 22 from line 16 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
24 Enter $5,000 ($2,500 if married, filing separately, and you were required to enter your spouse’s
earned income on line 20) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
25 Deductible benefits. Enter the smallest of line 21, 22, or 24. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
26 Enter the smaller of line 21 or 24 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
27 Enter the amount from line 25 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
28 Excluded benefits. Subtract line 27 from line 26. If zero or less, enter -0- . . . . . . . . . . . . . . . . . . . 28
29 Taxable benefits. Subtract line 28 from line 23. If zero or less, enter -0-. . . . . . . . . . . . . . . . . . . . . 29
To claim the child and dependent care credit, complete lines 30-34 below.
30 Enter $3,000 ($6,000 if two or more qualifying persons) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
31 Add lines 25 and 28 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
32 Subtract line 31 from line 30. If zero or less, stop. You cannot take the credit.
Exception: If you paid 2011 expenses in 2012, see Federal Form 2441 instructions, line 9 . . . . . 32
33 Complete line 2 on the front of this form. Do not include in Column (C) any benefits shown on
line 31 above. Then, add the amounts in Column (C) and enter the total here . . . . . . . . . . . . . . . . . 33
34 Enter the smaller of line 32 or 33. Also, enter this amount on line 3 on the front of this form and
complete lines 4-12 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
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