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Unformatted text preview: Worksheet and
Form W-10. Make your entries on these forms, not on this form.
Persons or Organizations Providing Care - You must complete this part.
Note: You can use Form W-10 to obtain the information below.
1. (a) Care
Provider Name (b) Address
Street, City, State, ZIP Nice Kids Day Care 567 Prospect St.
Lancaster Did you receive
dependent care benefits? NO
YES (c) ID no.
(SSN, EIN) (d) Amount
paid in 08 MS 87654 333-33-3555 3,000 Complete only Part II below.
Complete Part III on the back next. Caution: If the care was provided in your home, you may owe employment
taxes. If you do, you must use Form 1040. See Schedule H and its
instructions for details.
Part II Credit for Child and Dependent Care Expenses 2. Information about your qualifying person(s). See instrs. if more than 2
(a) Qualifying person's name
George Ramsay (b) Social
Security number (c) Qualified expenses you
incurred and paid in 2008 234-56-7890 3,000 3. Add the amounts in column (c) of line 2. DO NOT enter more
than $3,000 for one or $6,000 for two qualifying persons . . . ....
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- Winter '10