OMB No. 1545-1552 Qualified Adoption Expenses Form 8839

 Attach to Form 1040 or 1040A.

Department of the Treasury

Internal Revenue Service

Attachment

Sequence No. 38  See separate instructions.

Name(s) shown on return Your social security number

Information About Your Eligible Child or Children—You must complete this part. See page 2 of the

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

(b) 

Child’s year

of birth

(c) 

born before

1987 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 through 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 the instructions. Form 8839 (2004)

Before you begin: You need to understand the following terms. See Definitions on page 1 of 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 $155,860?

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), that begin on page 2, 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 page 4 of the instructions) 8

11

Subtract line 3 from line 2

12

13 Credit carryforward from prior years. Enter the amount, if any, from line 23 of your Credit

Carryforward Worksheet on page 4 of the 2003 Form 8839 instructions

14 Add lines 12 and 13 14

13

11

12

No. Enter -0-.

Yes. See page 3 of the instructions

for the amount to enter. 

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

Yes. Subtract $155,860 from line 8

Adoption credit. Enter the smaller of line 14 or line 17 here and on Form 1040, line 52, or

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

(see page 4 of the instructions)

15 Enter the amount from Form 1040, line 45, or Form 1040A, line 28

18

18

$10,390 $10,390

1040 filers: Enter the total of the amounts from Form

1040, lines 46 through 51, plus any mortgage

interest credit from Form 8396, line 11.

5

6

16

1040A filers: Enter the total of the amounts from Form

1040A, lines 29 through 33.

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 2004.

2004

(99)

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

line 53), complete Form 8396, Mortgage Interest Credit.

Enter your total qualified adoption

expenses (see page 3 of the instructions)
Form 8839 (2004) Page 2

Employer-Provided Adoption Benefits

Add the amounts on line 22

26

20

Enter your modified adjusted gross

income (from the worksheet on

page 5 of the instructions)

Is line 26 more than $155,860?

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 2004. This amount should be

shown in box 12 of your 2004 Form(s) W-2

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. Is line 30 more than line 23?

28

29

28  .

21

22

Enter the smaller of line 21 or line 22. But

if the child was a child with special needs

and the adoption became final in 2004,

enter the amount from line 21. 

24

29

27

You may be able to claim the adoption credit in Part II on the front of this form if either of the following apply.

23

24

22

20

Child 1 Child 2

25

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

-0- on line 30, and go to line 31

23

No. Enter -0-.

Yes. See page 4 of the instructions

for the amount to enter.

Subtract line 20 from line 19

19

21



Maximum exclusion per child 19

Form 8839 (2004)

No. Skip lines 27 and 28, and

enter -0- on line 29.

Yes. Subtract $155,860 from

line 26

30

31

$10,390 $10,390 00 00

No.

Yes.

● The total adoption expenses you paid in 2004 were not fully reimbursed by your employer and the adoption

became final in 2004 or earlier.

● You adopted a child with special needs and the adoption became final in 2004.

Subtract line 30 from line 23. Also, include this amount, if more than zero, on

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

Subtract line 23 from line 30. Enter the result as a negative number. Reduce the total

you would enter on line 7 of Form 1040 or 1040A by the amount on Form 8839, line

31, and enter the result on line 7 of Form 1040 or 1040A. On the line next to line 7,

enter “SNE.”

TIP