Schedule X (Form N-11/n-13/n-15) - Tax Credits For Hawaii Residents - 2012 Page 2

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SCHEDULE X (FORM N-11/N-13/N-15) (REV. 2012)

PAGE 2

Name(s) as shown on Form N-11, N-13, or N-15

Your social security number

PART III - CREDIT FOR CHILD AND DEPENDENT CARE EXPENSES

Section A: Care Provider Information

Complete line 1 columns (a) through (e) for each person or organization that provided the care. If you do

not give the information asked for in each column, or if the information you give is not correct, your credit

YCF122

and, if applicable, the exclusion of employer-provided dependent care benefits may be disallowed.

(a) Care

(b) Address

(d) Hawaii Tax

(e) Amount paid

Provider’s name

(number, street, city, state and Postal/ZIP code)

(SSN or FEIN)

I.D. Number

W __ __ __ __ __ __ __ __ - __ __

Section B: Dependent Care Benefits

— (If you did not receive benefits, skip to line 16)

2 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 W-2 form(s). If you were self-employed or a partner, include amounts you

received under a dependent care assistance program from your sole proprietorship or partnership. ...............................

3 Enter the amount, if any, you carried over from 2011 and used in 2012 during the grace period ......................................

4 Enter the amount, if any, you forfeited or carried forward to 2013. (See the Instructions) ................................................

(

)

5 Combine lines 2 through 4 .................................................................................................................................................

6 Enter the total amount of qualified expenses incurred in 2012 for the care of the qualifying person(s)...

7 Enter the smaller of line 5 or 6 .....................................................................................

8 Enter YOUR earned income ........................................................................................

9 If married filing a joint return, enter YOUR SPOUSE’S earned income (if student or

disabled, see the Instructions); if married filing separately, see the Instructions for the

amount to enter; all others, enter the amount from line 8 ............................................

10 Enter the smallest of line 7, 8, or 9 ..............................................................................

11 Taxable benefits. Enter the amount of taxable benefits from the worksheet in the Instructions. Also, include this

amount on Form N-13, line 7 or Form N-15, line 7. On the corresponding dotted line write “DCB”. ..................................

12 Enter $2,400 ($4,800 if two or more qualifying persons) ..............................................

13 Add lines f and i from the Taxable Benefits worksheet in the Instructions.....................

14 Line 12 minus line 13. If zero or less, STOP. You cannot take the credit. Exception. If you paid 2011

expenses in 2012 (See the Instructions) ...........................................................................................................................

15 Complete line 16. Do not include in column (d) any benefits shown on line 13. Then, add the amounts in column (d)

and enter the total here. .....................................................................................................................................................

Section C: Credit for Child and Dependent Care Expenses

— (If you are married, you must file a joint return to claim the tax credit.)

(d) Qualified expenses

(a) Qualifying person’s name

(b) Relationship

you incurred and paid

security number

in 2012 for the person

listed in column (a)

17 Add the amounts in column (d) of line 16. DO NOT enter more than $2,400 for one qualifying

person or $4,800 for two or more persons. If you completed Section B, enter the smaller of line 14 or line 15 ...

18 Enter YOUR earned income ........................................................................................

19 If married filing a joint return, enter YOUR SPOUSE’S earned income (if student or

disabled, see the Instructions); all others, enter the amount from line 18 ...................

20 Enter the smallest of line 17, 18, or 19. ............................................................................................................................

21 Enter adjusted gross income from Form N-11, line 20; Form N-13, line 11;

or Form N-15, line 35, Column A ..................................................................................

22 Enter on line 22 the decimal amount that applies to the amount on line 21. (See the Instructions) .................................

23 Multiply line 20 by the decimal amount on line 22. Enter the result here and on Form N-11, line 30;

Form N-13, line 20; or Form N-15, line 46. (Whole dollars only) ........................................................................................