Child and Dependant Care Expenses

 

 

Name:    Tax Year:

 

 

Care Provider Information

Care Provider

Address

Identifying Number Amount Paid

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Qualifying Persons

First Name

Last Name

Social Security # Qualified Expenses

 

Dependant Care Benefits Received:

 

 

Notes/Comments:

 

 your email address:       

[ Intake ] [ Income ] [ Itemized ] Child [ Un-Reimbursed ]
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