Dependent Information
You must provide more than 50% of the support for each dependent.
Dependent 1
First Name/MI
Last Name
Birth Date
Soc. Sec. #
Relationship
Months in Home
Disabled?
YES
Student?
YES
Child Care Expense
Hope Educ. Expense
Lifetime Educ. Expense
Dependent 3
First Name/MI
Last Name
Birth Date
Soc. Sec. #
Relationship
Months in Home
Disabled?
YES
Student?
YES
Child Care Expense
Hope Educ. Expense
Lifetime Educ. Expense
Dependent 2
First Name/MI
Last Name
Birth Date
Soc. Sec. #
Relationship
Months in Home
Disabled?
YES
Student?
YES
Child Care Expense
Hope Educ. Expense
Lifetime Educ. Expense
Dependent 4
First Name/MI
Last Name
Birth Date
Soc. Sec. #
Relationship
Months in Home
Disabled?
YES
Student?
YES
Child Care Expense
Hope Educ. Expense
Lifetime Educ. Expense
Child Care Credit Information
Persons or Organizations Who Provided Care: **NOTE: Break out expense by dependent above.
Provider's Name
Address (Number, Street, City, State, Zip)
Provider's Id Number
*
Amount Paid**
SSN:
EIN:
SSN:
EIN:
SSN:
EIN:
* List a Soc. Sec. # for an individual, or an Employer Identification Number for a business.
Advance Child Tax Credit payment received: