Form 2441 - Child And Dependent Care Expenses - 2017
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ORGANIZER
2017
1040
US
Child and Dependent Care Expenses (Form 2441)
33.1,33.2
Please enter all pertinent 2017 information. Last year's amounts are provided for your reference. You must have
paid for the care of one or more dependents enabling you to work or attend school to qualify for this credit.
2017 Amount
2016 Amount
DEPENDENT CARE EXPENSES (33.1)
Taxpayer
Spouse
Taxpayer
Spouse
Dependent care expenses incurred but not paid in 2017
. . .
Employer-provided benefits forfeited in 2017
. . . . . . . . . . . . . .
PERSONS AND EXPENSES QUALIFYING FOR DEPENDENT CARE CREDIT
First name
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Last name
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Title or suffix
. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Date of birth (m/d/y)
. . . . . . . . . . . . . . . . . . . . . .
No.
Social security number
. . . . . . . . . . . . . . . . . . . .
Qualified dependent care expenses
incurred and paid in 2017
2016 amt:
. . . . . . . . . . . . . . . . .
1=disabled
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1=spouse, 2=joint
. . . . . . . . . . . . . . . . . . . . . . . .
First name
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Last name
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Title or suffix
. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Date of birth (m/d/y)
. . . . . . . . . . . . . . . . . . . . . .
No.
Social security number
. . . . . . . . . . . . . . . . . . . .
Qualified dependent care expenses
incurred and paid in 2017
2016 amt:
. . . . . . . . . . . . . . . . .
1=disabled
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1=spouse, 2=joint
. . . . . . . . . . . . . . . . . . . . . . . .
PERSONS OR ORGANIZATIONS PROVIDING CARE (33.2)
Name of provider
. . . . . . . . . . . . . . . . . . . . . . . . .
Street address
. . . . . . . . . . . . . . . . . . . . . . . . . . .
City
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
State
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ZIP code
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
No.
Foreign region
. . . . . . . . . . . . . . . . . . . . . . . . . . . .
Foreign postal code
. . . . . . . . . . . . . . . . . . . . . . .
Foreign country
. . . . . . . . . . . . . . . . . . . . . . . . . .
Identification number (SSN or EIN)
. . . . . . . .
Amount paid to care provider in 2017
2016 amt:
. . . . . .
1=spouse, 2=joint
. . . . . . . . . . . . . . . . . . . . . . . .
33.1,33.2
Child and Dependent Care Expenses (Form 2441)
Series: 31, 34
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Parent category: Financial