Form W-10

(Rev. August 2009)

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 (SSN).

But if the provider is a nonresident or resident alien who does not

have and is not eligible to get an SSN, the TIN is an IRS individual

taxpayer identification number (ITIN). 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

How to get a TIN. Providers who do not have a TIN should apply

for one immediately. To apply for an SSN, get Form SS-5,

Application for a Social Security Card, from your local Social

Security Administration office. To apply for an ITIN, get Form W-7,

Application for IRS Individual Taxpayer Identification Number,

from the IRS. To apply for an EIN, get Form SS-4, Application for

Employer Identification Number, from the IRS.

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.

Part I

Part II

The individual or organization providing the care completes this

part.

Form W-10 (Rev. 8-2009)

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

Part I

Part II

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. For details, see the Form 2441 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 you are leaving the form with the

dependent care provider to return to you later.

Cat. No. 10437N

Specific Instructions

Note. An ITIN is for tax use only. It does not entitle the individual

to social security benefits or change his or her employment or

immigration status under U.S. law.

● 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.

Section references are to the Internal Revenue Code.

Purpose of form. 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 Form 1040 or 1040A, or

2. You receive benefits under your employer’s dependent care

plan.

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.

You may use Form W-10 or any of the other sources listed

under Due diligence below to get this information from each

provider.

Penalty for failure to furnish TIN. TINs are needed to carry out

the Internal Revenue laws of the United States. Section 6109(a)

requires a provider of dependent care services to give to you a

valid TIN, even if the provider is not required to file a return. The

IRS uses the TIN to identify the provider and verify the accuracy

of the provider’s return as well as yours.

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, later.

If incorrect information is reported. You will not be allowed the

tax credit or the exclusion for employer-provided dependent care

benefits if:

● You report an incorrect name, address, or TIN of the provider

on your Form 2441 and

● You cannot establish, to the IRS upon its request, that you used

due diligence in trying to get the required information.

Due diligence. You can show due diligence by getting and

keeping in your records any one of the following:

● A Form W-10 properly completed by the provider.

● A copy of the provider’s social security card or driver’s license

that includes his or her 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.