Child Care Credit Questionnaire
Client Information
Name:
Social Security Number:
Date of Birth:
-
Month
-
Day
Year
Date
Email Address:
example@example.com
Phone Number:
Format: (000) 000-0000.
Introduction
This Child Care Credit Questionnaire is designed to help us determine your eligibility for the Child and Dependent Care Credit, which can provide tax relief for individuals who pay for child care so they can work or look for work. Please answer the questions below carefully and accurately. Your responses will assist us in ensuring the appropriate tax credits are applied to your return.
General Child Care Information
1. Eligible Child Information
The Child and Dependent Care Credit can only apply to children under the age of 13 (or children of any age with a disability). Please list the children for whom you are seeking to claim this credit:
Child's Full Name:
Child's Date of Birth:
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Month
-
Day
Year
Date
Relationship to You (e.g., son, daughter, stepchild, etc.):
Please repeat for each child eligible for care.
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2. Type of Care
Please describe the type of care provided for your child(ren) during the tax year. Check all that apply:
Type of Care
Daycare Center
Babysitter/Nanny
After-School Program
Summer Camp
Other
3. Child Care Provider Information
For each care provider used, please provide the following information:
Provider 1
Name of Provider:
Address of Provider:
Phone Number of Provider:
Format: (000) 000-0000.
Employer Identification Number (EIN) or Social Security Number (SSN):
Provider 2 (If applicable)
Name of Provider:
Address of Provider:
Phone Number of Provider:
Format: (000) 000-0000.
Employer Identification Number (EIN) or Social Security Number (SSN):
Provider 3 (If applicable)
Name of Provider:
Address of Provider:
Phone Number of Provider:
Format: (000) 000-0000.
Employer Identification Number (EIN) or Social Security Number (SSN):
(If you have more than three providers, please attach a separate sheet with their information.)
4. Total Care Expenses
What were your total child care expenses for the year? Please break down the amount paid to each provider:
Provider 1 Expenses: $
Provider 2 Expenses: $
Provider 3 Expenses: $
Total Child Care Expenses: $
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5. Care Provided for the Purpose of Employment
Were the child care services provided to enable you (and/or your spouse, if applicable) to work or look for work?
Yes
No
If no, the expenses may not qualify for the credit. Please provide a brief explanation if necessary:
Eligibility for the Child Care Credit
1. Work-Related Care Requirement
To qualify for the Child Care Credit, you must have paid for care while you (and/or your spouse) worked or actively sought work. Were you (and/or your spouse) employed or seeking work during the year?
Yes
No
If yes, please provide details of your employment or job search during the year:
2. Marital Status and Filing Status
What is your marital status?
Single
Married, Filing Jointly
Married, Filing Separately
Head of Household
If married, did your spouse also work or actively seek work during the year?
Yes
No
3. Income Limitations
The Child and Dependent Care Credit is subject to income limitations. What was your total income for the year?
Your income: $
Spouse's income (if applicable): $
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Additional Information
1. Non-Standard Care Providers
If your care provider is a relative, such as a grandparent, sibling, or other family member, please indicate their relationship to the child and whether they are exempt from the SSN or EIN requirement:
Relationship to child:
Name of relative:
SSN/EIN:
(if applicable)
2. Expenses for Special Needs Children
If the child has a disability, please indicate whether additional services (e.g., specialized care or medical services) were needed.
Additional services needed?
Yes
No
If yes, please describe the nature of the special needs and any additional costs incurred:
Taxpayer Certification
By signing below, you certify that the information provided in this questionnaire is accurate and complete to the best of your knowledge. You understand that this information will be used in preparing your tax return, and any misrepresentation or omission may affect your eligibility for the Child and Dependent Care Credit.
Client Signature:
Date:
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Month
-
Day
Year
Date
Tax Preparer Signature:
Date:
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Month
-
Day
Year
Date
Instructions for Client:
Please review and complete all sections of this form. If you have any questions or need assistance in providing any of the information requested, please feel free to contact our office. Accurate and complete information is essential for ensuring that you receive the full benefits of the Child and Dependent Care Credit, if applicable.
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