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Get and Sign Form 2441 2016
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...
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