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 32

Enter your earned income. See instructions

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 37 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 2003 expenses in 2004, see

the instructions

9

For Paperwork Reduction Act Notice, see page 4 of the instructions. Form 2441 (2004)

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 61.

.

(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 2004 for the

person listed in column (a)

8

6

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

9

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

10

11

10

11

Enter the amount from Form 1040, line 45, minus any amount on Form 1040, line 46

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

here and on Form 1040, line 47

2004
Form 2441 (2004) Page 2

Dependent Care Benefits

Enter the total amount of dependent care benefits you received in 2004. Amounts you

received as an employee should be shown in box 10 of your Form(s) W-2. Do not include

amounts reported as wages in box 1 of Form(s) W-2. If you were self-employed or a partner,

include amounts you received under a dependent care assistance program from your sole

proprietorship or partnership

Enter the amount forfeited, if any (see the instructions)

Subtract line 13 from line 12

Enter the total amount of qualified expenses incurred

in 2004 for the care of the qualifying person(s)

13

15

Enter the smaller of line 14 or 15 16

14

Enter your earned income. See instructions

15

17

Enter the amount shown below that applies

to you.

18

Enter the smallest of line 16, 17, or 18

16

19

Enter the amount from line 12 that you received from your sole proprietorship or

partnership. If you did not receive any such amounts, enter -0-

17

20

Taxable benefits. Subtract line 26 from line 21. If zero or less, enter -0-. Also, include

this amount on Form 1040, line 7. On the dotted line next to line 7, enter “DCB”

18

27

Part III

To claim the child and dependent care

credit, complete lines 28–32 below.

28

29

30

19

20

27

28 Enter $3,000 ($6,000 if two or more qualifying persons)

Subtract line 29 from line 28. If zero or less, stop. You cannot take the credit.

Exception. If you paid 2003 expenses in 2004, see the instructions for line 9

Enter the smaller of line 30 or 31. Also, enter this amount on line 3 on the front of this

form and complete lines 4–11

Add lines 23 and 26

32

29

30

32

13

14

12

12

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

line 29 above. Then, add the amounts in column (c) and enter the total here

31

31

Form 2441 (2004)

● 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. 

21 Subtract line 20 from line 14

Enter $5,000 ($2,500 if married filing separately and you were required to enter your

spouse’s earned income on line 18)

22

Deductible benefits. Enter the smallest of line 19, 20, or 22. Also, include this amount

on the appropriate line(s) of your return (see the instructions)

23

24 Enter the smaller of line 19 or 22

25 Enter the amount from line 23

26 Excluded benefits. Subtract line 25 from line 24. If zero or less, enter -0-

24

25

21

22

23

26