Child Care Services Form

If your child(ren) went to an individual for childcare, please fill out this form. Please complete all fields.

Childcare Provider Information

First Name:

Last Name:

Email:

Telephone:

SSN or EIN:

Address:

City:

St:

Zip:

Children's Names

Name

First

Attachments

1099 Forms

Receipts

Bank Statement

Other:

Owner Certification

I certify that the information provided on this form is true and accurate to the best of my knowledge. I understand that deductions must comply with IRS rules and may be subject to verification:

IRS Disclaimer

This form is for information-gathering purposes only and does not guarantee acceptance of deductions by the Internal Revenue Service. Final eligibility is determined by IRS regulations.