Form D-2441 - Child And Dependent Care Credit For Part-Year Residents - 2011 Page 2

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*112410120000*
D-2441 PAGE 2
Enter your last name.
Enter your social security number.
Dependent care expenses
Complete for all people or organizations who provided care during 2011 so that you could work or look for work.
Round cents to
the nearest dollar.
Name
From (MM/DD)
To
(MM/DD)
Amount paid
.00
$
Address
Social security or Fed. employer ID
If an individual, identify their relationship to you
Name
From (MM/DD)
To
(MM/DD)
Amount paid
.00
$
Address
Social security or Fed. employer ID
If an individual, identify their relationship to you
Name
From (MM/DD)
To
(MM/DD)
Amount paid
.00
$
Address
Social security or Fed. employer ID
If an individual, identify their relationship to you
Name
From (MM/DD)
To
(MM/DD)
Amount paid
.00
$
Address
Social security or Fed. employer ID
If an individual, identify their relationship to you
Name
From (MM/DD)
To
(MM/DD)
Amount paid
.00
$
Address
Social security or Fed. employer ID
If an individual, identify their relationship to you
.00
6
Total expenses paid
$
2011 D-2441 P2
Child and Dependent Care Credit for Part-Year Residents
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