OMB No. 1545-1552 Qualified Adoption Expenses Form 8839

 Attach to Form 1040 or 1040A.

Department of the Treasury

Internal Revenue Service

Attachment

 See separate instructions. Sequence No. 38

Name(s) shown on return Your social security number

Information About Your Eligible Child or Children—You must complete this part. See the instructions for

details, including what to do if you need more space.

(b) 

Child’s year

of birth

(c) 

born before

1984 and

was disabled

1

(a) 

Child’s name

Adoption Credit

2

Did you file Form 8839 for a prior year?

Maximum credit per child

3

3

Enter the smaller of line 4 or line 5

4

5

Add the amounts on line 6. If zero, skip lines 8-11 and enter -0- on line 12 7

10 

Subtract line 11 from line 7

9

For Paperwork Reduction Act Notice, see page 5 of instructions. Form 8839 (2002)

Before you begin: You need to understand the following terms. See Definitions in the instructions.

Cat. No. 22843L

Part I

Part II

2

.

(d)

a child

with special

needs

(f)

Child’s

identifying number

First Last

Is line 8 more than $150,000?

6

9

7

Divide line 9 by $40,000. Enter the result as a decimal (rounded to at least three places). Do

not enter more than “1.000”

Multiply line 7 by line 10

8

4

Check if child was—

(e)

a

foreign

child

● Eligible Child ● Employer-Provided Adoption Benefits ● Qualified Adoption Expenses

Child

1

Child

2

Caution: If the child was a foreign child, see Special Rules in the instructions for line 1, column (e), before you complete Part II

or Part III. If you received employer-provided adoption benefits, complete Part III on the back next.

10

Child 1 Child 2

Enter your modified adjusted gross income (see instructions) 8

11

Subtract line 3 from line 2

Enter your total qualified adoption

expenses (see instructions)

12

13 Carryforward of adoption credit from prior years (see instructions)

14 Add lines 12 and 13 14

13

11

12

No. Enter -0-.

Yes. See the instructions for the

amount to enter. 

No. Skip lines 9 and 10, and enter -0- on line 11.

Yes. Subtract $150,000 from line 8

2002

1040 filers:

1040A filers: Enter the amount from Form 1040A, line 28.

Adoption credit. Enter the smaller of line 14 or line 17 here and on Form 1040, line 51, or

Form 1040A, line 34. If line 17 is smaller than line 14, you may have a credit carryforward (see

instructions)

15 Enter the amount from Form 1040, line 44.

18

18

$10,000 $10,000

1040 filers: Add the amounts from Form 1040, lines 45

through 50, and any mortgage interest

credit from Form 8396, line 11, and enter

the total.

5

6

16

1040A filers: Add the amounts from Form 1040A, lines

29 through 33, and enter the total.

17 Subtract line 16 from line 15

15

16 

17

00 00

Caution: Your qualified adoption expenses

may not be equal to the adoption expenses

you paid in 2002.

Before you begin: If you are filing Form 1040 and are claiming the mortgage interest credit (see the instructions for

Form 1040, line 52), first complete Form 8396.
Form 8839 (2002) Page 2

Employer-Provided Adoption Benefits

Add the amounts on line 22

26

20

Enter your modified adjusted gross

income (from the worksheet in the

instructions)

Is line 26 more than $150,000?

Excluded benefits. Subtract line 29 from line 25 30

31

Part III

27

Enter the total amount of

employer-provided adoption benefits you

received in 2002. This amount should be

shown in box 12 of your 2002 W-2 form(s)

with code T

Did you receive employer-provided

adoption benefits for a prior year?

Divide line 27 by $40,000. Enter the result as a decimal (rounded

to at least three places). Do not enter more than “1.000”

25

Multiply line 25 by line 28

26

Taxable benefits. Subtract line 30 from line 23. Also, include this amount on Form 1040,

line 7, or Form 1040A, line 7. On the line next to line 7, enter “AB”

28

29

28  .

21

22

24 Enter the smaller of line 21 or line 22

29

27

If the total adoption expenses you paid in 2002 were not fully reimbursed by your employer and the adoption became

final in or before 2002, you may be able to claim the adoption credit in Part II on the front of this form.

23

24

22

20

Child 1 Child 2

25

Add the amounts on line 24. If zero, skip lines 26-29, enter -0- on

line 30, and go to line 31

23

No. Enter -0-.

Yes. See the instructions for the

amount to enter.

Subtract line 20 from line 19

19

21



Maximum exclusion per child 19

Form 8839 (2002)

No. Skip lines 27 and 28, and

enter -0- on line 29.

Yes. Subtract $150,000 from

line 26

30

31

$10,000 $10,000 00 00