Form W-10

(Rev. August 1994)

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 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 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, 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 IRS office.

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

(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.—TINs 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 even if they are 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.

● 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.

Part I

Part II

The individual or organization providing the care completes this

part.

Form W-10 (Rev. 8-94)

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 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:

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 will 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 later.

Cat. No. 10437N

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.

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

under Due diligence below to get this information from each

provider.

Specific Instructions

Printed on recycled paper