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

● If you are claiming the child and dependent care credit, complete Parts I and II below. But if you received employer-provided dependent

care benefits, first complete Part III on the back.

● If you are not claiming the credit but you received employer-provided dependent care benefits, only complete Part I below and Part III

on the back.

Persons or Organizations Who Provided the Care—You must complete this part. (See the instructions.

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) Name

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

Note: If you paid cash wages of $50 or more in a calendar quarter to an individual for services performed in your home, you

must file an employment tax return. Get Form 942 for details.

Credit for Child and Dependent Care Expenses

Enter the number of qualifying persons cared for in 1991. (See the instructions for the definition of a qualifying

person.) Caution: To qualify, the person(s) must have shared the same home with you in 1991 ©

3

Enter the amount of qualified expenses you incurred and actually paid in 1991. See the instructions

to find out which expenses qualify. Caution: If you completed Part III on page 2, do not include on

this line any excluded benefits shown on line 25

4

4

Enter $2,400 ($4,800 if you paid for the care of two or more

qualifying persons)

5

5

If you completed Part III on page 2, enter the excluded benefits,

if any, from line 25

6

6

Subtract line 6 from line 5. (If the result is zero or less, skip lines 8 through 13. Enter -0- on

line 14, and go to line 15.)

7

7

8 Compare the amounts on lines 4 and 7. Enter the smaller of the two amounts here 8

9 You must enter your earned income. (See the instructions for the definition of earned income.) 9

If you are married filing a joint return, you must enter your spouse’s earned income. (If your

spouse was a full-time student or disabled, see the instructions for the amount to enter.)

10

10

Note: If you are not filing a joint return, skip line 10 and go to line 11.

11

11

● If you are married filing a joint return, compare the amounts on

lines 8, 9, and 10. Enter the smallest of the three amounts here.

12 12

● All others, compare the amounts on lines 8 and 9. Enter the

smaller of the two amounts here.

Enter the amount from Form 1040, line 32 

13 13 3

If line 12 is: Decimal amount is: If line 12 is: Decimal amount is:

But not

over—

But not Over—

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

14 Multiply line 11 above by the decimal amount on line 13 14

Multiply any qualified expenses for 1990 that you paid in 1991 by the decimal amount that

applies to the amount on your 1990 Form 1040, line 32, or Form 1040A, line 17. (You must

complete Part I and attach a statement. See the instructions.)

15

15

Add lines 14 and 15. See the instructions for the amount of credit you can claim

For Paperwork Reduction Act Notice, see separate instructions. Form 2441 (1991)

Caution: If you have a child who was born in 1991 and the amount on Form 1040, line 32, is less than $21,250, see page 1 of the instructions

before completing this form.

Cat. No. 11862M

Part I

Part II

Enter the decimal amount from the table below that applies to the amount on line 12 

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16 16
Form 2441 (1991) Page 2

Employer-Provided Dependent Care Benefits—Complete this part only if you received employer-provided

dependent care benefits. Also, be sure to complete Part I.

17 Enter the total amount of employer-provided dependent care benefits you received for 1991.

(This amount should be shown in Box 22 of your W-2 form(s).) Do not include amounts that

were reported to you as wages in Box 10 of Form(s) W-2 17

18 Enter the amount forfeited, if any. Caution: See the instructions 18

19 Subtract line 18 from line 17 19

Enter the total amount of qualified expenses incurred in 1991 for the care of a qualifying

person. (See the instructions.)

20

20

21 Compare the amounts on lines 19 and 20. Enter the smaller of the two amounts here 21

You must enter your earned income. (See the instructions for lines 9 and 10 for the definition

of earned income.)

22

22

If you were married at the end of 1991, you must enter your spouse’s earned income. (If your

spouse was a full-time student or disabled, see the instructions for lines 9 and 10 for the

amount to enter.)

23

23

● If you were married at the end of 1991, compare the amounts

on lines 22 and 23. Enter the smaller of the two amounts here.

24

24

● If you were unmarried, enter the amount from line 22 here.

25 Excluded benefits. Enter here the smallest of the following:

● The amount from line 21, or

● The amount from line 24, or 25

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

Taxable benefits. Subtract line 25 from line 19. Enter the result, but not less than zero. Also,

include this amount in the total on Form 1040, line 7. On the dotted line next to line 7, write

“DCB”

Note: If you are also claiming the child and dependent care credit, fill in Form 1040 through line 40. Then complete Part II

of this form.

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26

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Part III

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