Form 2441
Department of the Treasury
Internal Revenue Service (99)
Child and Dependent Care Expenses
▶ Attach to Form 1040, Form 1040A, or Form 1040NR.
▶ Go to www.irs.gov/Form2441 for instructions and the
latest information.
1040A
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1040
2441
◀
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1040NR
OMB No. 1545-0074
2017
Attachment
Sequence No. 21
Name(s) shown on return Your social security number
Part I Persons or Organizations Who Provided the Care—You must complete this part.
(If you have more than two care providers, see the instructions.)
1(a) Care provider’s
name
(b) Address
(number, street, apt. no., city, state, and ZIP code)
(c) Identifying number
(SSN or EIN)
(d) Amount paid
(see instructions)
Did you receive
dependent care benefits?
No ▶Complete only Part II below.
Yes ▶Complete Part III on the back next.
Caution: If the care was provided in your home, you may owe employment taxes. If you do, you can’t file Form 1040A. For details, see
the instructions for Form 1040, line 60a, or Form 1040NR, line 59a.
Part II Credit for Child and Dependent Care Expenses
2 Information about your qualifying person(s). If you have more than two qualifying persons, see the instructions.
(a) Qualifying person’s name
(b) Qualifying person’s social
security number
(c) Qualified expenses you
incurred and paid in 2017 for the
