Form W-10

(Rev. August 1992)

Dependent Care Provider’s Identification and Certification

Department of the Treasury

Internal Revenue Service

Dependent Care Provider’s Identification (See instructions.)

Name of dependent care provider Provider’s taxpayer identification number

Address (number, street, and apt. no.) If the above number is a social security

number, check here ©

City, state, and ZIP code

Please print or type

Certification and Signature of Dependent Care Provider.—Under penalties of perjury, I, as the dependent care provider, certify

that my name, address, and taxpayer identification number shown above are correct.

Dependent care provider’s signature Date Please

Sign

Here

Name and Address of Person Requesting Part I Information (See instructions.)

Name, street address, apt. no., city, state, and ZIP code of person requesting information

Enter the provider’s name, address, and

TIN. For individuals and sole

proprietors, the TIN is a social security

number. For other entities, it is the

employer identification number. If the

provider is exempt from Federal income

tax as an organization described in section

501(c)(3), see Tax-exempt dependent

care provider below.

General Instructions If Incorrect Information Is Reported

● You report an incorrect name, address,

or TIN of the provider on your Form 2441

or Schedule 2, and

● You cannot establish, to the IRS upon

its request, that you used due diligence in

trying to get the required information. How to get a TIN.—Providers who do not

have a TIN should apply for one

immediately. To apply for a number,

individuals and sole proprietors should get

Form SS-5, Application for a Social

Security Card, from their local Social

Security Administration office. Other

entities should get Form SS-4, Application

for Employer Identification Number, from

their local Internal Revenue Service office.

Due Diligence

● A Form W-10 properly completed by the

provider.

● A copy of the provider’s social security

card or driver’s license (in a state where

the license includes the social security

number).

● A recently printed letterhead or printed

invoice that shows the provider’s name,

address, and TIN.

● If the provider is your employer’s

dependent care plan, a copy of the

statement provided by your employer

under the plan. Penalty for Failure To Furnish TIN

● If the provider is your household

employee and he or she gave you a

properly completed Form W-4, Employee’s

Withholding Allowance Certificate, to have

income tax withheld, a copy of that Form

W-4.

Income tax reporting requirements for

dependent care providers.—The

individual provider must report on his or

her income tax return all income received

for providing care for any person. If the

provider is a self-employed individual, the

income is reported on Schedule C or C-EZ

(Form 1040), whichever applies. For

information on reporting this income, see

the Instructions for Form 1040.

Part I

Part II

The individual or organization providing the

care completes this part.

Form W-10 (Rev. 8-92)

Do NOT file Form W-10 with your tax return. Instead, keep it for your records.

(Section references are to the Internal

Revenue Code.)

Part I

Part II

Purpose

If your care provider does not comply

with your request for one of these items,

you must still report certain information on

your Form 2441 or Schedule 2, whichever

applies. For details, see the Form 2441 or

Schedule 2 instructions.

Tax-exempt dependent care provider.—A

provider who is a tax-exempt organization

described in section 501(c)(3) and exempt

under section 501(a) is not required to

supply its TIN. Instead, the provider must

complete the name and address lines and

write "tax-exempt" in the space for the

TIN. Generally, an exempt 501(c)(3)

organization is one organized and operated

exclusively for religious, charitable,

scientific, testing for public safety, literary,

or educational purposes, or for the

prevention of cruelty to children or animals.

Complete this part only if your care

provider is going to return the form to you

later.

If either 1 or 2 above applies, you must

show the correct name, address, and

taxpayer identification number (TIN) of

each care provider on Form 2441, Child

and Dependent Care Expenses, or

Schedule 2, Child and Dependent Care

Expenses for Form 1040A Filers, whichever

applies.

A care provider who does not give you

his or her correct TIN is subject to a

penalty of $50 for each failure unless the

failure is due to reasonable cause and not

willful neglect. This penalty does not apply

to an organization described in section

501(c)(3). See Tax-exempt dependent

care provider on this page.

Cat. No. 10437N

You must get the information shown in

Part I from each person or organization

that provides care for your child or other

dependent if:

1. You plan to claim a credit for child

and dependent care expenses on your

Form 1040 or 1040A, or

2. You receive benefits under your

employer’s dependent care plan.

You may use Form W-10 or any of the

other sources listed under Due Diligence

on this page to get this information from

each provider.

You will not be allowed the tax credit or

the exclusion for employer-provided

dependent care benefits if:

You can show due diligence by getting and

keeping in your records any one of the

following:

Specific Instructions

Taxpayer identification numbers are

needed to carry out the Internal Revenue

laws of the United States. Section 6109(a)

requires the providers of your dependent

care services to give you their TIN. The IRS

uses the TIN for identification purposes

and to help verify the accuracy of the

provider’s return as well as yours.

Providers must give you their TIN even if

they are not required to file a tax return.