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 $3,000 for one qualifying

person or $6,000 for two or more persons. If you completed Part III, enter the amount

from line 26

Enter your earned income

3

3

If married filing jointly, 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 35 7



Decimal

amount is

If line 7 is:

Decimal

amount is

If line 7 is:

But not

Over over

But not

Over over

$0—15,000 .35 $29,000—31,000 .27

15,000—17,000 .34 31,000—33,000 .26

17,000—19,000 .33 33,000—35,000 .25

19,000—21,000 .32 35,000—37,000 .24

21,000—23,000 .31 37,000—39,000 .23

23,000—25,000 .30

Multiply line 6 by the decimal amount on line 8. If you paid 2002 expenses in 2003, see

the instructions 

9

For Paperwork Reduction Act Notice, see page 3 of the instructions. Form 2441 (2003)

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 59.

.

(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 2003 for the

person listed in column (a)

8

6

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

10 Enter the amount from Form 1040, line 43, minus any amount on Form 1040, line 44 

Credit for child and dependent care expenses. Enter the smaller of line 9 or line 10

here and on Form 1040, line 45

11

9

10

11

25,000—27,000

27,000—29,000

.29

.28

39,000—41,000

41,000—43,000

43,000—No limit

.22

.21

.20

2003
Form 2441 (2003) Page 2

Dependent Care Benefits

Enter the total amount of dependent care benefits you received for 2003. 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 13 from line 12

Enter the total amount of qualified expenses incurred

in 2003 for the care of the qualifying person(s)

13

15

Enter the smaller of line 14 or 15 16

14

Enter your earned income

15

17

Enter the amount shown below that

applies to you.

18

Enter the smallest of line 16, 17, or 18

16

19

Excluded benefits. Enter here the smaller of the following:

17

20

● The amount from line 19 or

● $5,000 ($2,500 if married filing separately and you

were required to enter your spouse’s earned

income on line 18).

Taxable benefits. Subtract line 20 from line 14. Also, include this amount on Form 1040,

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

18

21

Part III



To claim the child and dependent care

credit, complete lines 22–26 below.

22

23

24

19

20

21

22 Enter $3,000 ($6,000 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 2002 expenses in 2003, see the instructions for line 9

Enter the smaller of line 24 or 25. Also, enter this amount on line 3 on the front of this

form and complete lines 4–11

Enter the amount from line 20

26

23

24

26

13

14

12

12

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

on line 20 above. Then, add the amounts in column (c) and enter the total here

25

25

Form 2441 (2003)

● If married filing jointly, enter your

spouse’s earned income (if your spouse

was a student or was disabled, see the

instructions for line 5).

● If married filing separately, see the

instructions for the amount to enter.

● All others, enter the amount from line 17.