Form 2441

Department of the Treasury 

Internal Revenue Service (99) 

 Child and Dependent Care Expenses

▶ Attach to Form 1040, Form 1040A, or Form 1040NR.

▶ Information about Form 2441 and its separate instructions is at

www.irs.gov/form2441.

1040A 

. . . . . . . . . . 

1040 

2441

◀ . . . . . . . . . . 

1040NR 

OMB No. 1545-0074

2012

Attachment 

Sequence No. 21

Name(s) shown on return Your social security number

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

(If you have more than two care providers, see the instructions.)

1 (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)

Did you receive 

dependent care benefits?

No ▶ Complete only Part II below.

Yes ▶ Complete Part III on the back next.

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 Form 1040, line 59a, or Form 1040NR, line 58a.

Part II Credit for Child and Dependent Care Expenses

2 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 2012 for the

person listed in column (a)

3 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 31 . . . . . . . . . . . . . . . . . . . . . . . . . . 3 

4 Enter your earned income. See instructions . . . . . . . . . . . . . . . 4 

5 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 . . . . 5 

6 Enter the smallest of line 3, 4, or 5 . . . . . . . . . . . . . . . . . . 6 

7 Enter the amount from Form 1040, line 38; Form 

1040A, line 22; or Form 1040NR, line 37. . . . . 7 

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

If line 7 is:

Over

But not 

over

Decimal 

amount is

$0—15,000 .35

15,000—17,000 .34

17,000—19,000 .33

19,000—21,000 .32

21,000—23,000 .31

23,000—25,000 .30

25,000—27,000 .29

27,000—29,000 .28

If line 7 is:

Over

But not 

over

Decimal 

amount is

$29,000—31,000 .27

31,000—33,000 .26

33,000—35,000 .25

35,000—37,000 .24

37,000—39,000 .23

39,000—41,000 .22

41,000—43,000 .21

43,000—No limit .20

8 X .

9 Multiply line 6 by the decimal amount on line 8. If you paid 2011 expenses in 2012, see 

the instructions . . . . . . . . . . . . . . . . . . . . . . . . . 9 

10 Tax liability limit. Enter the amount from the Credit 

Limit Worksheet in the instructions. . . . . . . 10 

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

here and on Form 1040, line 48; Form 1040A, line 29; or Form 1040NR, line 46 . . . . 11 

For Paperwork Reduction Act Notice, see your tax return instructions. Cat. No. 11862M Form 2441 (2012)
Form 2441 (2012) Page 2

Part III Dependent Care Benefits

12 Enter the total amount of dependent care benefits you received in 2012. 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 . . . . . . . . . . . . . . . . . . 12 

13 Enter the amount, if any, you carried over from 2011 and used in 2012 during the grace 

period. See instructions . . . . . . . . . . . . . . . . . . . . . . . 13 

14 Enter the amount, if any, you forfeited or carried forward to 2013. See instructions . . . 14 ( )

15 Combine lines 12 through 14. See instructions . . . . . . . . . . . . . . . 15 

16 Enter the total amount of qualified expenses incurred 

in 2012 for the care of the qualifying person(s) . . . 16 

17 Enter the smaller of line 15 or 16 . . . . . . . . 17 

18 Enter your earned income. See instructions . . . . 18 

19 Enter the amount shown below that applies 

to you. 

• 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 

instructions.

• All others, enter the amount from line 18.

} . . . 19 

20 Enter the smallest of line 17, 18, or 19 . . . . . . 20 

21 Enter $5,000 ($2,500 if married filing separately and

you were required to enter your spouse’s earned 

income on line 19). . . . . . . . . . . . . 21 

22 Is any amount on line 12 from your sole proprietorship or partnership? (Form 1040A filers 

go to line 25.)

No. Enter -0-.

Yes. Enter the amount here . . . . . . . . . . . . . . . . . . . . 22 

23 Subtract line 22 from line 15 . . . . . . . . . 23 

24 Deductible benefits. Enter the smallest of line 20, 21, or 22. Also, include this amount on

the appropriate line(s) of your return. See instructions . . . . . . . . . . . . . 24 

25 Excluded benefits. Form 1040 and 1040NR filers: If you checked "No" on line 22, enter 

the smaller of line 20 or 21. Otherwise, subtract line 24 from the smaller of line 20 or line

21. If zero or less, enter -0-. Form 1040A filers: Enter the smaller of line 20 or line 21 . . 25 

26 Taxable benefits. Form 1040 and 1040NR filers: Subtract line 25 from line 23. If zero or 

less, enter -0-. Also, include this amount on Form 1040, line 7; or Form 1040NR, line 8. On

the dotted line next to Form 1040, line 7; or Form 1040NR, line 8, enter “DCB.”

Form 1040A filers: Subtract line 25 from line 15. Also, include this amount on Form 1040A, 

line 7. In the space to the left of line 7, enter “DCB” . . . . . . . . . . . . . . 26 

To claim the child and dependent care 

credit, complete lines 27 through 31 below.

27 Enter $3,000 ($6,000 if two or more qualifying persons) . . . . . . . . . . . . 27 

28 Form 1040 and 1040NR filers: Add lines 24 and 25. Form 1040A filers: Enter the amount

from line 25 . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 

29 Subtract line 28 from line 27. If zero or less, stop. You cannot take the credit. 

Exception. If you paid 2011 expenses in 2012, see the instructions for line 9 . . . . . 29 

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

on line 28 above. Then, add the amounts in column (c) and enter the total here. . . . . 30 

31 Enter the smaller of line 29 or 30. Also, enter this amount on line 3 on the front of this form

and complete lines 4 through 11 . . . . . . . . . . . . . . . . . . . . 31 

Form 2441 (2012)