Form W-10 - Dependent Care Provider'S Identification And Certification

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Dependent Care Provider’s Identification and Certification
(Rev. July 2011)
Do NOT file Form W-10 with your tax return. Instead, keep it for your records.
Department of the Treasury
Internal Revenue Service
Part I
Dependent Care Provider’s Identification (See instructions.)
Provider’s taxpayer identification number
Name of dependent care provider
Address (number, street, and apt. no.)
If the above number is a social security
number, check here
City, state, and ZIP code
Certification and Signature of Dependent Care Provider. Under penalties of perjury, I, as the dependent care provider, certify that my
name, address, and taxpayer identification number shown above are correct.
Dependent care provider’s signature
Part II
Name and Address of Person Requesting Part I Information (See instructions.)
Name, street address, apt. no., city, state, and ZIP code of person requesting information
General Instructions
• If the provider is your household employee and he or she gave
you a properly completed Form W-4, Employee’s Withholding
Section references are to the Internal Revenue Code.
Allowance Certificate, to have income tax withheld, a copy of that
Purpose of form. You must get the information shown in Part I
Form W-4.
from each person or organization that provides care for your child or
If your care provider does not comply with your request for one
other dependent if:
of these items, you must still report certain information on your
1. You plan to claim a credit for child and dependent care
Form 2441. For details, see the Form 2441 instructions.
expenses on Form 1040 or 1040A, or
Specific Instructions
2. You receive benefits under your employer’s dependent care
Part I
If either 1 or 2 above applies, you must show the correct name,
address, and taxpayer identification number (TIN) of each care
The individual or organization providing the care completes this
provider on Form 2441, Child and Dependent Care Expenses.
You may use Form W-10 or any of the other sources listed under
Enter the provider’s name, address, and TIN. For individuals and
Due diligence below to get this information from each provider.
sole proprietors, the TIN is a social security number (SSN). But if the
provider is a nonresident or resident alien who does not have and is
Penalty for failure to furnish TIN. TINs are needed to carry out the
not eligible to get an SSN, the TIN is an IRS individual taxpayer
Internal Revenue laws of the United States. Section 6109(a)
identification number (ITIN). For other entities, it is the employer
requires a provider of dependent care services to give to you a
identification number. If the provider is exempt from federal income
valid TIN, even if the provider is not required to file a return. The
tax as an organization described in section 501(c)(3), see Tax-
IRS uses the TIN to identify the provider and verify the accuracy of
exempt dependent care provider below.
the provider’s return as well as yours.
How to get a TIN. Providers who do not have a TIN should apply
A care provider who does not give you his or her correct TIN is
for one immediately. To apply for an SSN, get Form SS-5,
subject to a penalty of $50 for each failure unless the failure is due
Application for a Social Security Card, from your local Social
to reasonable cause and not willful neglect. This penalty does not
Security Administration office. To apply for an ITIN, get Form W-7,
apply to an organization described in section 501(c)(3). See Tax-
Application for IRS Individual Taxpayer Identification Number, from
exempt dependent care provider, later.
the IRS. To apply for an EIN, get Form SS-4, Application for
If incorrect information is reported. You will not be allowed the
Employer Identification Number, from the IRS.
tax credit or the exclusion for employer-provided dependent care
Note. An ITIN is for tax use only. It does not entitle the individual to
benefits if:
social security benefits or change his or her employment or
• You report an incorrect name, address, or TIN of the provider on
immigration status under U.S. law.
your Form 2441 and
Tax-exempt dependent care provider. A provider who is a tax-
• You cannot establish, to the IRS upon its request, that you used
exempt organization described in section 501(c)(3) and exempt
due diligence in trying to get the required information.
under section 501(a) is not required to supply its TIN. Instead, the
Due diligence. You can show due diligence by getting and keeping
provider must complete the name and address lines and write “tax-
in your records any one of the following:
exempt” in the space for the TIN. Generally, an exempt 501(c)(3)
• A Form W-10 properly completed by the provider.
organization is one organized and operated exclusively for religious,
charitable, scientific, testing for public safety, literary, or educational
• A copy of the provider’s social security card or driver’s license
purposes, or for the prevention of cruelty to children or animals.
that includes his or her social security number.
Part II
• A recently printed letterhead or printed invoice that shows the
provider’s name, address, and TIN.
Complete this part only if you are leaving the form with the
• If the provider is your employer’s dependent care plan, a copy of
dependent care provider to return to you later.
the statement provided by your employer under the plan.
(Rev. 7-2011)
Cat. No. 10437N


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