Form W-10

(Rev. July 2011) 

Department of the Treasury 

Internal Revenue Service 

Dependent Care Provider’s Identification and Certification 

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

Part I Dependent Care Provider’s Identification (See instructions.) 

Please 

print 

or 

type 

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 

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. 

Please 

Sign 

Here

Dependent care provider’s signature Date 

Part II 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 

General Instructions 

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 Taxexempt 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. 

• 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. 

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. 

Specific Instructions 

Part I 

The individual or organization providing the care completes this 

part. 

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 Taxexempt dependent care provider below. 

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. 

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. 

Tax-exempt dependent care provider. A provider who is a taxexempt 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 “taxexempt” 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. 

Part II 

Complete this part only if you are leaving the form with the 

dependent care provider to return to you later. 

Cat. No. 10437N Form W-10 (Rev. 7-2011)