romW-10

(January 1989)

Department of the Treasury
Internal Revenue Service

Dependent Care Provider’s Identification and Certification

ntification (See instructions)

Dependent Care Provider's Ider
Name of dependent care provider

Provider's taxpayer identification number

Address (number and street)

If the above number is a social security
number check this box >

O

City, state, and ZIP code

Please print or type

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

name, address, and taxpayer identification num!

ber, as shown above, are correct.

fDi
Please | Signature of Dependent Care Provider

Sign
Here

Date

Name of Taxpayer Requesting

Part | Information (See instructions)

Name, street address, city, state, and ZIP code of person(s) requesting information

General Information

Due to recent changes in the law, 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 if you file Form 1040,
or Schedule 1 if you file Form 1040A. You
will have to report this information on your
1989 tax return which you will file in 1990.

You may use Form W- 10 to get this
information from each provider or you may
use any one of the other methods described
under /f Incorrect Information Is Reported,
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) of the Internal Revenue
Code 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 (other
than a tax-exempt organization described in
Internal Revenue Code section 501(c)(3))
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.

Part I

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 is a
social security number For other entities, it
is the employer identification number Ifthe
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 If 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
Number 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 Is an 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)
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.

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 required to be reported on
Schedule C (Form 1040). For information
on reporting this income, see the
instructions for Form 1040.

Part Il

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

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.

You can show that you exercised due
diligence 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
e 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.

tr USGPO 1988- 245-489/99129

Form W-10 (1-89)