Form

2441

Child and Dependent Care Expenses
▶

Department of the Treasury
Internal Revenue Service (99)

▶

1040
1040A. .
........

..........

Attach to Form 1040, Form 1040A, or Form 1040NR.

OMB No. 1545-0074

◀
2441

Information about Form 2441 and its separate instructions is at www.irs.gov/form2441. 1

Attachment
Sequence No. 21
Your social security number

Name(s) shown on return

Part I

2015

1040NR

Persons or Organizations Who Provided the Care—You must complete this part.
(If you have more than two care providers, see the instructions.)

(a) Care provider’s name (b) Address
(number, street, apt. no., city, state, and ZIP code)

(c) Identifying number
(SSN or EIN)

(d) Amount paid
(see instructions)

▶ Complete only Part II below.
No
Did you receive dependent care benefits?
▶ Complete Part III on the back next.
Yes
Caution. If the care was provided in your home, you may owe employment taxes. If you do, you cannot file Form 1040A. For details, see the instructions for Form 1040, line 60a, or Form 1040NR, line 59a.

Part II
2

Credit for Child and Dependent Care Expenses

Information about your qualifying person(s). If you have more than two qualifying persons, see the instructions.
(b) Qualifying person’s social security number

(a) Qualifying person’s name
Last

First

3

Add the amounts in column (c) of line 2. Do not enter more than $3,000 for one qualifying person or $6,000 for two or more persons. If you completed Part III, enter the amount from line 31 . . . . . . . . . . . . . . . . . . . . . . . . . .

4
5

Enter your earned income. See instructions . . . . . . . . . . . . . . .
If married filing jointly, enter your spouse’s earned income (if you or your spouse was a student or was disabled, see the instructions); all others, enter the amount from line 4 .