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’s

name

2 Add the amounts in column (d) of line 1 2

Credit for Child and Dependent Care Expenses

Enter the number of qualifying persons cared for in 1995 ©

4 Enter the amount of qualified expenses you incurred and paid in

1995. 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 25

5 Enter YOUR earned income 5

If married filing a joint return, enter YOUR SPOUSE’S earned

income (if student or disabled, see the instructions); all others,

enter the amount from line 5

6

6

7 Enter the smallest of line 4, 5, or 6 7

8 Enter the amount from Form 1040, line 32 8

9

3

Decimal

amount

is

Decimal If line 8 is—

amount

is

If line 8 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

10

Multiply line 7 by the decimal amount on line 9. Enter the result. Then, see the instructions for

the amount of credit to enter on Form 1040, line 41

10

For Paperwork Reduction Act Notice, see separate instructions. Form 2441 (1995)

You need to understand the following terms to complete this form:

Qualifying Person(s), Dependent Care Benefits, Qualified

Expenses, and Earned Income. See Important Terms on page 1

of the Form 2441 instructions.

Cat. No. 11862M

Part I

Part II

Enter on line 9 the decimal amount shown below that applies to the amount on line 8

Did you receive

dependent care benefits? YES

NO

4

9

3

Complete only Part II below.

Complete Part III on the back now.

©

©

Caution: If you paid a person who worked in your home, you may have to pay employment taxes. See the instructions for

Form 1040, line 53, on page 26.

.

(99)
Form 2441 (1995) Page 2

Dependent Care Benefits—Complete this part only if you received these benefits.

Enter the total amount of dependent care benefits you received for 1995. 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

11

Subtract line 12 from line 11

11

Enter the total amount of qualified expenses incurred in 1995

for the care of the qualifying person(s)

12

14

Enter the smaller of line 13 or 14 15

13

Enter YOUR earned income

14

16

If married filing a joint return, enter YOUR SPOUSE’S earned

income (if student or disabled, see the line 6 instructions); if

married filing a separate return, see the instructions for the

amount to enter; all others, enter the amount from line 16 17

Enter the smallest of line 15, 16, or 17

15

18

Excluded benefits. Enter here the smaller of the following:

16

19

● The amount from line 18, or

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

and you were required to enter your spouse’s

earned income on line 17).

Taxable benefits. Subtract line 19 from line 13. Also, include this amount on Form 1040,

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

17

20

Part III

%

To claim the child and dependent care credit, complete

lines 21–25 below, and lines 4–10 on the front of this form.

21

22

23

24

Enter the amount of qualified expenses you incurred and paid in 1995. DO NOT include on

this line any excluded benefits shown on line 19

18

19

20

21

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

Subtract line 23 from line 22. If zero or less, STOP. You cannot take the credit. Exception. If

you paid 1994 expenses in 1995, see the line 10 instructions

Enter the smaller of line 21 or 24 here and on line 4 on the front of this form

Enter the amount from line 19

25

23

24

25

12

13

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