Form W-1 0

(Rev August 1990)

Department of the Treasury
Internal Revenue Service

(Do NOT file with your tax return. Kee|

Dependent Care Provider’s Identification and Certification

p for your records.)

Dependent Care Provider's Ide!

ntification (See instructions)

Name of dependent care provider

Provider's taxpayer identification number

Address (number and street)

If the above number 1s a social security
number, check this box

O

City, state, and ZIP code

Please print or type

Certification and Signature of Dependent Cai

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

re Provider.—Under penalties of perjury. |,

as the dependent care provider, certify that my

Signature of Dependent Care Provider Date
Please
Sign
Here
Name of Taxpayer Requesting Part | Information (See instructions)
Name, street address, city, state, and ZIP code of person(s) requesting information
General Information Part I Part Il

‘Section references are to the Internal
evenue Code.)

You are required to get the information in
Part | from anyone who provides care for
your child or other dependent if:

@ you intend to claim a tax credit on your
tax return for child and dependent care
expenses; or

@ you receive benefits from a dependent
care assistance program provided by your
employer

You will have to report the correct name,
address, and taxpayer identification number
(TIN) of the dependent care provider on the
child and dependent care credit form, which
is Form 2441, Child and Dependent Care
Expenses, if you file Form 1040, or
Schedule 2, Child and Dependent Care
Expenses for Form 1040A Filers, if you file
Form 1040A. You will have to report this
information on your income tax return,

You may use Form W-10 to get this
information from each provider or you may
use any one of the other sources described
under Due Diligence, below. Do not file
Form W-10 with your income tax return.
Instead, keep it for your records.

Penalty for Failure To Furnish TIN.—This
information is needed to carry out the
Internal Revenue laws of the United States.
Section 6109(a) requires anyone providing
dependent care services to you to give you
this information. IRS uses the TIN for
identification purposes and to help verify
the accuracy of the provider's return as well
as your return. Providers must give you their
TIN whether or not they are required to file
a tax return

if the dependent care provider does not
furnish his or her correct TIN to you, the
provider is subject to a penalty of $50 for
each such failure unless the failure is due to
reasonable cause and not willful neglect.
This penaity does not apply to an organi:
zation described in section 501(c)(3).

The individual or organization providing the
dependent care services completes this part.

The provider's name, address, and
taxpayer identification number (TIN) should
be entered in the spaces above. For
individuals and sole proprietors, the TIN isa
social security number For other entities, it
is the employer identification number If the
provider does not have a TIN, see How To
Get a TIN, below.

If the provider is exempt from Federal
income tax as an organization described in
section 501(c)(3), see /f Dependent Care
Provider Is an Exempt Organization, below.

How To Get a TIN.—Providers who do not
have a TIN should apply for one
immediately. To apply for the number, they
should get Form SS-5, Application for a
Social Security Card (for individuals), from
the local office of the Social Security
Administration, or Form SS-4, Application
for Employer Identification Number (for
businesses and other entities), from the
local Internal Revenue Service office.

If Dependent Care Provider Isa
Tax-Exempt Organization.—If the
dependent care provider is a tax-exempt
organization of the type described in section
501(c)(3), the provider is not required to
supply its TIN. In such cases, the
organization completes the name and
address part of Form W-10 and writes
“tax-exempt” in the space for the TIN
Generally, the type of exempt organization
described in section 501(c)(3) 1s 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.

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

1s a self-employed individual, the income Is

required to be reported on Schedule C (Form

1040). For information on reporting this
income, see the instructions for Form 1040.

You only need to complete this part if you
give Form W-10 to your dependent care
provider and it is to be returned to you later

Other Information

If Incorrect Information Is Reported.— You
will not be allowed the tax credit or the
income exclusion for employer-provided
dependent care assistance if:

@ you report an incorrect name, address, or
TIN of the provider on your income tax
return; and

you cannot establish, to the IRS upon its
request, that you exercised due diligence in
obtaining this information.

Due Diligence.—You can show that you
exercised due diligence in obtaining this
information by getting and keeping:

@ a Form W-10 properly completed by the
provider: or

© a copy of the provider's social security
card or driver's license (in a state where the
license includes the social security
number); or

@ arecently printed letterhead or printed
invoice that has on it the provider's name,
address, and TIN; or

@ where the employer is the provider, a
copy of the statement furnished by the
employer under a dependent care
assistance program, showing the
employer's name, address, and TIN; or

@ where the provider is your household
employee and has given you a properly
completed Form W-4 to have income tax
withheld, a copy of that Form W-4,

If your care provider does not comply with
your request for one of these items, you
must still furnish the name, address, and, if
known, the TIN of the care provider on Form
2441 or Schedule 2. Also, you should
include a statement on Form 2441 or
Schedule 2 that you requested the
information and that the care provider did
not comply with the request. This statement
will show that you exercised due diligence,
unless you know that the statement is
incorrect.

Form W-10 (Rev. 8-90)