OMB No. 1545-0068 Child and Dependent Care Expenses Form 2441

 Attach to Form 1040.

Department of the Treasury

Internal Revenue Service

Attachment

 See separate instructions. Sequence No. 21

Name(s) shown on Form 1040 Your social security number

Persons or Organizations Who Provided the Care—You must complete this part. 

(If you need more space, use the bottom of page 2.)

(b) Address

(number, street, apt. no., city, state, and ZIP code)

(d) Amount paid

(see instructions)

(c) Identifying number

(SSN or EIN) 1 (a) Care provider’sname

Credit for Child and Dependent Care Expenses

2

Add the amounts in column (c) of line 2. Do not enter more than $2,400 for one qualifying

person or $4,800 for two or more persons. If you completed Part III, enter the amount

from line 24

Enter your earned income

3

3

If married filing a joint return, enter your spouse’s earned income (if your spouse was a

student or was disabled, see the instructions); all others, enter the amount from

line 4

4 4

Enter the smallest of line 3, 4, or 5

5

5

6

7 Enter the amount from Form 1040, line 34 7



Decimal

amount is

If line 7 is:

Decimal

amount is

If line 7 is:

But not

Over over

But not

Over over

$0—10,000 .30 $20,000—22,000 .24

10,000—12,000 .29 22,000—24,000 .23

12,000—14,000 .28 24,000—26,000 .22

14,000—16,000 .27 26,000—28,000 .21

16,000—18,000 .26 28,000—No limit .20

18,000—20,000 .25

9

Multiply line 6 by the decimal amount on line 8. Enter the result here and on Form 1040,

line 44. But if this amount is more than the amount on Form 1040, line 42, minus any

amount on line 43, or you paid 2000 expenses in 2001, see the instructions for the amount

to enter on line 44

9

For Paperwork Reduction Act Notice, see page 3 of the instructions. Form 2441 (2001)

Before you begin: You need to understand the following terms. See Definitions on page 1 of the instructions.

Cat. No. 11862M

Part I

Part II

Enter on line 8 the decimal amount shown below that applies to the amount on line 7

Did you receive

dependent care benefits? Yes

No

8

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. See the instructions for Form 1040, line 57.

.

(99)

Information about your qualifying person(s). If you have more than two qualifying persons, see the instructions.

(a) Qualifying person’s name

First Last

(b) Qualifying person’s social

security number

(c) Qualified expenses you

incurred and paid in 2001 for the

person listed in column (a)

8

6

● Dependent Care Benefits ● Qualifying Person(s) ● Qualified Expenses ● Earned Income

2001
Form 2441 (2001) Page 2

Dependent Care Benefits

Enter the total amount of dependent care benefits you received for 2001. This amount

should be shown in box 10 of your W-2 form(s). Do not include amounts that were

reported to you as wages in box 1 of Form(s) W-2

Enter the amount forfeited, if any. See the instructions

Subtract line 11 from line 10

Enter the total amount of qualified expenses incurred

in 2001 for the care of the qualifying person(s)

11

13

Enter the smaller of line 12 or 13 14

12

Enter your earned income

13

15

If married filing a joint return, enter your spouse’s earned

income (if your spouse was a student or was disabled,

see the instructions for line 5); if married filing a separate

return, see the instructions for the amount to enter;

all others, enter the amount from line 15 16

Enter the smallest of line 14, 15, or 16

14

17

Excluded benefits. Enter here the smaller of the following:

15

18

● The amount from line 17 or

● $5,000 ($2,500 if married filing a separate return

and you were required to enter your spouse’s

earned income on line 16).

Taxable benefits. Subtract line 18 from line 12. Also, include this amount on Form 1040,

line 7. On the dotted line next to line 7, enter “DCB”

16

19

Part III



To claim the child and dependent care

credit, complete lines 20–24 below.

20

21

22

17

18

19

20 Enter $2,400 ($4,800 if two or more qualifying persons)

Subtract line 21 from line 20. If zero or less, stop. You cannot take the credit.

Exception. If you paid 2000 expenses in 2001, see the instructions for line 9

Enter the smaller of line 22 or 23. Also, enter this amount on line 3 on the front of this

form and complete lines 4–9

Enter the amount from line 18

24

21

22

24

11

12

10

10

Complete line 2 on the front of this form. Do not include in column (c) any benefits shown

on line 18 above. Then, add the amounts in column (c) and enter the total here

23

23

Form 2441 (2001)