Form It-540 Web - Louisiana Resident - 2014 Page 10
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11ATTACH TO RETURN IF COMPLETED.
2014 Louisiana Refundable Child Care Credit Worksheet
(For use with Form IT-540)
Your Name
Social Security Number
Your Federal Adjusted Gross Income must be $25,000 or less in order to complete this form. See instructions on page 31.
1. Care Provider Information Schedule – Complete columns A through D for each person or organization that provided care to your child. You may
use Federal Form W-10, supplied by your provider, to obtain the information. If your care provider does not provide a Federal Form W-10, complete
those parts of the Care Provider Information Schedule for which you have the information. You must follow the same rules of “Due Diligence” as the
IRS requires if you do not have all of the care provider information. See IRS 2014 Publication 503 for information on “Due Diligence.” If additional
lines are required for Lines 1 or 2, attach a schedule. Falsifi cation of any information provided on this form constitutes fraud and can result
in criminal penalties.
Care Provider Information Schedule
A
B
C
D
Address (number, street, apartment
Identifying number
Amount paid
Care provider’s name
number, city, state, and ZIP)
(SSN or EIN)
(See instructions.)
.00
.00
.00
.00
.00
2. For each child under age 13, enter their name in column E, their Social Security Number in column F, and the amount of Qualifi ed Expenses you
incurred and paid in 2014 in column G. See the defi nitions on page 31 for information on Qualifi ed Expenses.
E
F
G
Qualifi ed expenses you
Qualifying person’s name
Qualifying person’s
incurred and paid in 2014 for
Social Security Number
First
Last
the person listed in column (E)
.00
.00
.00
.00
.00
Add the amounts in column G, Line 2. Do not enter more than $3,000 for one qualifying person or
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$6,000 for two or more persons. Enter this amount here and on Form IT-540, Line 19A.
.00
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4
Enter your earned income. See the defi nitions on page 31.
.00
If married fi ling jointly, enter your spouse’s earned income (if your spouse was a student or was
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disabled, see IRS Publication 503). All other fi ling statuses, enter the amount from Line 4.
.00
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Enter the smallest of Lines 3, 4, or 5. Enter this amount on Form IT-540, Line 19B.
.00
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Enter your Federal Adjusted Gross Income from Form IT-540, Line 7, or Schedule E, Line 1 if fi led.
.00
Enter on Line 8 the decimal amount shown below that applies to the amount on Line 7.
If Line 7 is:
over
but not over
decimal amount
$0
$15,000
.35
X . _______
$15,000
$17,000
.34
8
8
$17,000
$19,000
.33
$19,000
$21,000
.32
$21,000
$23,000
.31
$23,000
$25,000
.30
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Multiply Line 6 by the decimal amount on Line 8.
.00
X .50
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10 Multiply Line 9 by 50 percent and enter this amount on Line 11.
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11 Enter this amount on Form IT-540, Line 19.
.00
61515
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