W-4S Request for Federal Income Tax Withholding from Sick Pay

Caution: DRAFT FORM
This is an advance proof copy of an IRS tax form.
It is subject to change and OMB approval before it
is officially released. You can check the scheduled
release date on our web site (www.irs.gov).
If you have any comments on this draft form, you can
submit them to us on our web site. Include the word
DRAFT in your response. You may make comments
anonymously, or you may include your name and
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we receive. However, we will carefully consider
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your comments, please send them to us within 30
days from the date the draft was posted.

4
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TLS, have you
transmitted all R
text files for this
cycle update?
Date

2441

Date

Signature

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INK: BLACK

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Form

Action

Revised proofs
requested

OMB No. 1545-0074

Child and Dependent Care Expenses

2006

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©

Department of the Treasury
Internal Revenue Service (99)

Attach to Form 1040 or Form 1040NR.
©

Name(s) shown on Form 1040

Attachment
Sequence No.

See separate instructions.

21

Your social security number

Before you begin: You need to understand the following terms. See Definitions on page 1 of the instructions.
● Qualifying Person(s)
● Qualified Expenses
● Dependent Care Benefits
Part I
1

Persons or Organizations Who Provided the Care—You must complete this part.
(If you need more space, use the bottom of page 2.)

(a) Care provider’s
name

(b) Address
(number, street, apt. no., city, state, and ZIP code)

Did you receive
dependent care benefits?

(c) Identifying number
(SSN or EIN)

(d) Amount paid
(see instructions)

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. See the instructions for Form 1040, line 62, or Form
1040NR, line 57.

Part II
2

Credit for Child and Dependent Care Expenses

Information about your qualifying person(s). If you have more than two qualifying persons, see the instructions.
(a) Qualifying person’s name
First

3

4
5
6
7
8

(b) Qualifying person’s social
security number

Last

Add the amounts in column (c) of line 2. Do not enter more than $3,000 for one qualifying
person or $6,000 for two or more persons. If you completed Part III, enter the amount from
line 33
Enter your earned income. See instructions
If married filing jointly, enter your spouse’s earned income (if your spouse was a student
or was disabled, see the instructions); all others, enter the amount from line 4
Enter the smallest of line 3, 4, or 5
Enter the amount from Form 1040, line 38, or Form
7
1040NR, line 36

(c) Qualified expenses you
incurred and paid in 2006 for the
person listed in column (a)

3
4
5
6

Enter on line 8 the decimal amount shown below that applies to the amount on line 7
If line 7 is:
Over

But not
over

$0—15,000
15,000—17,000
17,000—19,000
19,000—21,000
21,000—23,000
23,000—25,000
25,000—27,000
27,000—29,000

If line 7 is:
Decimal
amount is
.35
.34
.33
.32
.31
.30
.29
.28

Over

But not
over

$29,000—31,000
31,000—33,000
33,000—35,000
35,000—37,000
37,000—39,000
39,000—41,000
41,000—43,000
43,000—No limit

Decimal
amount is
.27
.26
.25
.24
.23
.22
.21
.20

3.

8

9

Multiply line 6 by the decimal amount on line 8. If you paid 2005 expenses in 2006, see
9
the instructions
10 Enter the amount from Form 1040, line 46, minus any amount on Form 1040, line 47, or
10
Form 1040NR, line 43, minus any amount on Form 1040NR, line 44
11 Credit for child and dependent care expenses. Enter the smaller of line 9 or line 10
11
here and on Form 1040, line 48, or Form 1040NR, line 45
For Paperwork Reduction Act Notice, see page 4 of the instructions.
Cat. No. 11862M

Form

2441

(2006)

4
I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

INSTRUCTIONS TO PRINTERS
FORM 2441, PAGE 2 of 2
MARGINS: TOP 13 mm (1⁄ 2 "), CENTER SIDES.
PAPER: WHITE WRITING, SUB. 20. INK: BLACK
FLAT SIZE: 203 mm (8") 3 279 mm (11")
PERFORATE: NONE

PRINTS: HEAD TO HEAD

DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Form 2441 (2006)

Part III Dependent Care Benefits
12

13
14
15
16
17
18
19

20
21
22
23
24
25
26
27
28

Page

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Enter the total amount of dependent care benefits you received in 2006. Amounts you
received as an employee should be shown in box 10 of your Form(s) W-2. Do not include
amounts reported as wages in box 1 of Form(s) W-2. If you were self-employed or a partner,
include amounts you received under a dependent care assistance program from your sole
proprietorship or partnership
Enter the amount, if any, you carried over from 2005 and used in 2006 during the grace
period. See instructions
Enter the amount, if any, you forfeited or carried forward to 2007. See instructions
Combine lines 12 through 14. See instructions
Enter the total amount of qualified expenses incurred
16
in 2006 for the care of the qualifying person(s)
17
Enter the smaller of line 15 or 16
18
Enter your earned income. See instructions
Enter the amount shown below that applies
to you.
● If married filing jointly, enter your
spouse’s earned income (if your spouse
was a student or was disabled, see the
instructions for line 5).
19
● If married filing separately, see the
instructions for the amount to enter.
● All others, enter the amount from line 18.

20
Enter the smallest of line 17, 18, or 19
Enter the amount from line 12 that you received from your sole proprietorship or partnership.
If you did not receive any such amounts, enter -022
Subtract line 21 from line 15
Enter $5,000 ($2,500 if married filing separately and you were required to enter your
spouse’s earned income on line 19)
Deductible benefits. Enter the smallest of line 20, 21, or 23. Also, include this amount
on the appropriate line(s) of your return. See instructions
25
Enter the smaller of line 20 or 23
26
Enter the amount from line 24
Excluded benefits. Subtract line 26 from line 25. If zero or less, enter -0Taxable benefits. Subtract line 27 from line 22. If zero or less, enter -0-. Also, include this
amount on Form 1040, line 7, or Form 1040NR, line 8. On the dotted line next to Form
1040, line 7, or Form 1040NR, line 8, enter “DCB”

2

12

13
14 (
15

)

21

23
24

27

28

To claim the child and dependent care
credit, complete lines 29–33 below.
29
30
31
32
33

Enter $3,000 ($6,000 if two or more qualifying persons)
Add lines 24 and 27
Subtract line 30 from line 29. If zero or less, stop. You cannot take the credit.
Exception. If you paid 2005 expenses in 2006, see the instructions for line 9
Complete line 2 on the front of this form. Do not include in column (c) any benefits shown
on line 30 above. Then, add the amounts in column (c) and enter the total here
Enter the smaller of line 31 or 32. Also, enter this amount on line 3 on the front of this
form and complete lines 4–11

29
30
31
32
33
Form

2441

(2006)

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Fileid: I2441.SGM

Leading adjust: 20%
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(Init. & date)

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Ok to Print

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Page 1 of 4

Instructions for Form 2441

11:40 - 14-NOV-2005

The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.

2005

Department of the Treasury
Internal Revenue Service

Instructions for Form 2441
Child and Dependent Care Expenses
What’s New
Generally, you no longer need to pay
over half the cost of keeping up a
home for a qualifying person.
However, the qualifying person must
have lived with you for more than half
of 2005. See Qualifying Person(s) on
this page and Who Can Take the
Credit or Exclude Dependent Care
Benefits? on page 2 for more
information.

Purpose of Form
If you paid someone to care for your
child or other qualifying person so
you (and your spouse if filing a joint
return) could work or look for work in
2005, you may be able to take the
credit for child and dependent care
expenses. You (and your spouse if
filing a joint return) must have earned
income to take the credit. But see
Spouse Who Was a Student or
Disabled on page 3. If you can take
the credit, use Form 2441 to figure
the amount of your credit.
If you (or your spouse if filing a
joint return) received any dependent
care benefits for 2005, you must use
Form 2441 to figure the amount, if
any, of the benefits you may exclude
from your income on Form 1040, line
7. You must complete Part III of Form
2441 before you can figure the credit,
if any, in Part II.

Definitions
Dependent Care Benefits
These include amounts your
employer paid directly to either you or
your care provider for the care of your
qualifying person(s) while you
worked. These benefits also include
the fair market value of care in a
daycare facility provided or
sponsored by your employer. Your
salary may have been reduced to pay
for these benefits. If you received
dependent care benefits as an
employee, they should be shown in
box 10 of your 2005 Form(s) W-2.
Benefits you received as a partner
should be shown in box 13 of your

Schedule K-1 (Form 1065) with
code O.

Qualifying Person(s)
A qualifying person is:
• A qualifying child under age 13
whom you can claim as a dependent.
If the child turned 13 during the year,
the child is a qualifying person for the
part of the year he or she was under
age 13.
• Your disabled spouse who is not
able to care for himself or herself.
• Any disabled person not able to
care for himself or herself whom you
can claim as a dependent (or could
claim as a dependent except that the
person had gross income of $3,200
or more or filed a joint return.)
• Any disabled person not able to
care for himself or herself whom you
could claim as a dependent except
that you (or your spouse if filing a
joint return), could be claimed as a
dependent on someone else’s 2005
return.
If you are divorced or separated,
see Special rule for children of
divorced or separated parents below.
To find out who is a qualifying child
and who is a dependent, see Pub.
501, Exemptions, Standard
Deduction, and Filing Information.
To be a qualifying person, the
person must have lived with
CAUTION you for more than half of
2005. Special rules may apply for
people who had to relocate because
of Hurricane Katrina. See Pub. 4492
for details.

!

Special rule for children of
divorced or separated parents.
Even if you cannot claim your child as
a dependent, he or she is treated as
your qualifying person if:
• The child was under age 13 or was
physically or mentally not able to care
for himself or herself,
• You were the child’s custodial
parent (the parent with whom the
child lived for the greater part of
2005), and
• The noncustodial parent is entitled
to claim the child as a dependent
Cat. No. 10842K

under the special rules for a child of
divorced or separated parents.
If this special rule applies, the
noncustodial parent cannot treat the
child as a qualifying person.
To find out when a noncustodial
parent is entitled to claim the
dependency exemption for a child,
see Pub. 501.

Qualified Expenses
These include amounts paid for
household services and care of the
qualifying person while you worked or
looked for work. Child support
payments are not qualified expenses.
Also, expenses reimbursed by a state
social service agency are not
qualified expenses unless you
included the reimbursement in your
income.

Household Services
These are services needed to care
for the qualifying person as well as to
run the home. They include, for
example, the services of a cook,
maid, babysitter, housekeeper, or
cleaning person if the services were
partly for the care of the qualifying
person. Do not include services of a
chauffeur or gardener.
You can also include your share of
the employment taxes paid on wages
for qualifying child and dependent
care services.

Care of the Qualifying Person
Care includes the cost of services for
the qualifying person’s well-being and
protection. It does not include the
cost of clothing or entertainment.
You can include the cost of care
provided outside your home for your
dependent under age 13 or any other
qualifying person who regularly
spends at least 8 hours a day in your
home. If the care was provided by a
dependent care center, the center
must meet all applicable state and
local regulations. A dependent care
center is a place that provides care
for more than six persons (other than
persons who live there) and receives
a fee, payment, or grant for providing

Page 2 of 4

Instructions for Form 2441

11:40 - 14-NOV-2005

The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.

services for any of those persons,
even if the center is not run for profit.

Married Persons Filing
Separate Returns

You can include amounts paid for
items other than the care of your child
(such as food and schooling) only if
the items are incidental to the care of
the child and cannot be separated
from the total cost. But do not include
the cost of schooling for a child in
kindergarten or above. You can
include the cost of a day camp, even
if it specializes in a particular activity,
such as soccer. But do not include
any expenses for sending your child
to an overnight camp.

If your filing status is married filing
separately and all of the following
apply, you are considered unmarried
for purposes of figuring the credit and
the exclusion on Form 2441.
• You lived apart from your spouse
during the last 6 months of 2005,
• The qualifying person lived in your
home more than half of 2005, and
• You provided over half the cost of
keeping up your home.
If you meet all the requirements to
be treated as unmarried and meet
items 2 through 5 listed earlier, you
can take the credit or the exclusion. If
you do not meet all the requirements
to be treated as unmarried, you
cannot take the credit. However, you
can take the exclusion if you meet
items 2 through 5.

Medical Expenses
Some disabled spouse and
dependent care expenses may
qualify as medical expenses if you
itemize deductions on Schedule A
(Form 1040). However, you cannot
claim the same expense as both a
dependent care expense and a
medical expense. See Pub. 503,
Child and Dependent Care Expenses,
and Pub. 502, Medical and Dental
Expenses, for details.

Who Can Take the Credit
or Exclude Dependent
Care Benefits?
You can take the credit or the
exclusion if all five of the following
apply.
1. Your filing status is single, head
of household, qualifying widow(er), or
married filing jointly. But see Married
Persons Filing Separate Returns on
this page.
2. The care was provided so you
(and your spouse if filing a joint
return) could work or look for work.
However, if you did not find a job and
have no earned income for the year,
you cannot take the credit or the
exclusion. But if your spouse was a
student or disabled, see the
instructions for line 5.
3. The care must be for one or
more qualifying persons.
4. The person who provided the
care was not your spouse, the parent
of your qualifying child under age 13,
or a person whom you can claim as a
dependent. If your child provided the
care, he or she must have been age
19 or older by the end of 2005.
5. You report the required
information about the care provider
on line 1 and, if taking the credit, the
information about the qualifying
person on line 2.

Line Instructions
Line 1
Complete columns (a) through (d) for
each person or organization that
provided the care. You can use Form
W-10, Dependent Care Provider’s
Identification and Certification, or any
other source listed in its instructions
to get the information from the care
provider. If you do not give correct or
complete information, your credit (and
exclusion, if applicable) may be
disallowed unless you can show you
used due diligence in trying to get the
required information.

Due Diligence
You can show a serious and earnest
effort (due diligence) to get the
information by keeping in your
records a Form W-10 completed by
the care provider. Or you may keep
one of the other sources of
information listed in the instructions
for Form W-10. If the provider does
not give you the information,
complete the entries you can on
line 1. For example, enter the
provider’s name and address. Enter
“See Page 2” in the columns for
which you do not have the
information. Then, on the bottom of
page 2, explain that the provider did
not give you the information you
requested.

a care provider), enter your
employer’s name in column (a). Next,
enter “See W-2” in column (b). Then,
leave columns (c) and (d) blank. But if
your employer paid a third party (not
hired by your employer) on your
behalf to provide the care, you must
give information on the third party in
columns (a) through (d).

Column (c)
If the care provider is an individual,
enter his or her social security
number (SSN). Otherwise, enter the
provider’s employer identification
number (EIN). If the provider is a
tax-exempt organization, enter
“Tax-Exempt” in column (c).

Column (d)
Enter the total amount you actually
paid in 2005 to the care provider.
Also, include amounts your employer
paid to a third party on your behalf. It
does not matter when the expenses
were incurred. Do not reduce this
amount by any reimbursement you
received.

Line 2
Complete columns (a) through (c) for
each qualifying person. If you have
more than two qualifying persons,
attach a statement to your return with
the required information. Be sure to
put your name and social security
number (SSN) on the statement.
Also, enter “See Attached” on the
dotted line next to line 3.

Column (a)
Enter each qualifying person’s name.

Column (b)
You must enter the qualifying
person’s SSN. Be sure the name and
SSN entered agree with the person’s
social security card. Otherwise, at the
time we process your return, we may
reduce or disallow your credit. If the
person was born and died in 2005
and did not have an SSN, enter
“Died” in column (b) and attach a
copy of the person’s birth certificate.
To find out how to get an SSN, see
Social Security Number (SSN) on
page 16 of the Form 1040
instructions. If the name or SSN on
the person’s social security card is
not correct, call the Social Security
Administration at 1-800-772-1213.

Columns (a) and (b)

Column (c)

Enter the care provider’s name and
address. If you were covered by your
employer’s dependent care plan and
your employer furnished the care
(either at your workplace or by hiring

Enter the qualified expenses you
incurred and paid in 2005 for the
person listed in column (a). Prepaid
expenses are treated as paid in the
year the care is provided. Do not

-2-

Page 3 of 4

Instructions for Form 2441

11:40 - 14-NOV-2005

The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.

include in column (c) qualified
expenses:
• You incurred in 2005 but did not
pay until 2006. You may be able to
use these expenses to increase your
2006 credit.
• You incurred in 2004 but did not
pay until 2005. Instead, see the
instructions for line 9 on page 3.
• You prepaid in 2005 for care to be
provided in 2006. These expenses
can only be used to figure your 2006
credit.
If you paid qualified expenses
TIP for the care of two or more
qualifying persons, the $6,000
limit does not need to be divided
equally. For example, if you paid and
incurred $2,500 of qualified expenses
for the care of one qualifying person
and $3,500 for the care of another
qualifying person, you can use the
total, $6,000, to figure the credit.

Line 4
Earned income for figuring the credit
includes the following amounts. If
filing a joint return, figure your and
your spouse’s earned income
separately.
1. The amount shown on Form
1040, line 7, minus (a) any amount
included for a scholarship or
fellowship grant that was not reported
to you on a Form W-2, (b) any
amount also reported on Schedule
SE (Form 1040) because you were a
member of the clergy or you received
$108.28 or more of church employee
income, and (c) any amount received
as a pension or annuity from a
nonqualified deferred compensation
plan or a nongovernmental section
457(b) plan. This amount may be
reported in box 11 of Form W-2. If
you received such an amount but box
11 is blank, contact your employer for
the amount received as a pension or
annuity.
2. The amount shown on
Schedule SE, line 3, minus any
deduction you claim on Form 1040,
line 27. If you use either optional
method to figure self-employment tax,
subtract any deduction you claim on
Form 1040, line 27, from the total of
the amounts shown on Schedule SE,
Section B, lines 3 and 4b. If you
received church employee income of
$108.28 or more, subtract any
deduction you claim on Form 1040,
line 27, from the total of the amounts
shown on Schedule SE, Section B,
lines 3, 4b, and 5a.
3. If you are filing Schedule C or
C-EZ (Form 1040) as a statutory

employee, the amount shown on line
1 of the schedule.
4. Certain nontaxable earned
income such as meals and lodging
provided for the convenience of your
employer and nontaxable combat
pay. See Pub. 503 for details.

!

CAUTION

You must reduce your earned
income by any loss from
self-employment.

Special Situations
If you are filing a joint return,
disregard community property laws. If
your spouse died in 2005, see Pub.
503. If your spouse was a student or
disabled in 2005, see the instructions
for line 5.

Line 5
Spouse Who Was a Student or
Disabled
Your spouse was a student if he or
she was enrolled as a full-time
student at a school during any 5
months of 2005. A school does not
include an on-the-job training course,
correspondence school, or Internet
school. Your spouse was disabled if
he or she was not capable of
self-care. Figure your spouse’s
earned income on a monthly basis.
For each month or part of a month
your spouse was a student or was
disabled, he or she is considered to
have worked and earned income. His
or her earned income for each month
is considered to be at least $250
($500 if more than one qualifying
person was cared for in 2005). If your
spouse also worked during that
month, use the higher of $250 (or
$500) or his or her actual earned
income for that month. If, in the same
month, both you and your spouse
were either students or disabled, only
one of you can be treated as having
earned income in that month.
For any month that your spouse
was not a student or disabled, use
your spouse’s actual earned income if
he or she worked during the month.
Special rules may apply for
people who had to relocate
CAUTION because of Hurricane Katrina.
See Pub. 4492 for details.

!

Line 9
Credit for Prior Year’s
Expenses
If you had qualified expenses for
2004 that you did not pay until 2005,
-3-

you may be able to increase the
amount of credit you can take in
2005. To figure the credit, see the
worksheet under Amount of Credit in
Pub. 503. If you can take a credit for
your 2004 expenses, enter the
amount of the credit and “CPYE” on
the dotted line next to line 9. Also,
enter the name and social security
number of the person for whom you
paid the prior year’s expenses to the
right of this amount. Then, add the
credit to the amount on line 9 and
replace the amount on line 9 with that
total. Also, attach a statement
showing how you figured the credit.

Line 13
If you had a flexible spending
account, enter on line 13 the total of
the following amounts included on
line 12.
• Any amount you forfeited. You
forfeited an amount if you did not
receive it because you did not incur
the expense. Do not include amounts
you expect to receive at a future date.
• Any amount you did not receive but
are permitted by your employer to
carry forward and use in the following
year during a grace period.
Example. Under your employer’s
dependent care plan, you chose to
have your employer set aside $5,000
to cover your 2005 dependent care
expenses. The $5,000 is shown in
box 10 of your Form W-2. In 2005,
you incurred and were reimbursed for
$4,950 of qualified expenses. You
would enter $5,000 on line 12 and
$50, the amount forfeited, on line 13.
You would also enter $50 on line 13
if, instead of forfeiting the amount,
your employer permitted you to carry
the $50 forward to use during the
grace period in 2006.

Line 15
Enter the total of all qualified
expenses incurred in 2005 for the
care of your qualifying person(s). It
does not matter when the expenses
were paid.
Example. You received $2,000 in
cash under your employer’s
dependent care plan for 2005. The
$2,000 is shown in box 10 of your
Form W-2. Only $900 of qualified
expenses were incurred in 2005 for
the care of your 5-year-old dependent
child. You would enter $2,000 on
line 12 and $900 on line 15.

Page 4 of 4

Instructions for Form 2441

11:40 - 14-NOV-2005

The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.

Line 17
Earned income for figuring the
amount of dependent care benefits
you are able to exclude or deduct
from your income includes the
following amounts. If filing a joint
return, figure your and your spouse’s
earned income separately.
1. The amount shown on Form
1040, line 7, minus (a) any amount
included for a scholarship or
fellowship grant that was not reported
to you on a Form W-2, (b) any
amount also reported on Schedule
SE (Form 1040) because you were a
member of the clergy or you received
$108.28 or more of church employee
income, and (c) any amount received
as a pension or annuity from a
nonqualified deferred compensation
plan or a nongovernmental section
457(b) plan. This amount may be
reported in box 11 of Form W-2. If
you received such an amount but box
11 is blank, contact your employer for
the amount received as a pension or
annuity.
2. The amount shown on
Schedule SE, line 3, minus any
deduction you claim on Form 1040,
line 27. If you use either optional
method to figure self-employment tax,
subtract any deduction you claim on
Form 1040, line 27, from the total of
the amounts shown on Schedule SE,
Section B, lines 3 and 4b. If you
received church employee income of
$108.28 or more, subtract any
deduction you claim on Form 1040,
line 27, from the total of the amounts
shown on Schedule SE, Section B,
lines 3, 4b, and 5a.
3. If you are filing Schedule C or
C-EZ (Form 1040) as a statutory
employee, the amount shown on line
1 of the schedule.
4. Nontaxable combat pay, if you
elect to include it in earned income.

However, including this income will
only give you a larger exclusion or
deduction if your (or your spouse’s)
other earned income is less than the
amount entered on line 16. To make
the election, include all of your
nontaxable combat pay in the amount
you enter on line 17 (line 18 for your
spouse if filing jointly). If you are filing
a joint return and both you and your
spouse received nontaxable combat
pay, you can each make your own
election. The amount of your
nontaxable combat pay should be
shown in box 12 of Form(s) W-2 with
code Q.
For purposes of line 17,
earned income does not
CAUTION include any dependent care
benefits shown on line 12.

!
!

CAUTION

You must reduce your earned
income by any loss from
self-employment.

Special Situations
If you are filing a joint return,
disregard community property laws. If
your spouse died in 2005, see Pub.
503. If your spouse was a student or
disabled in 2005, see the instructions
for line 5.

Line 18
If your filing status is married filing
separately, see Married Persons
Filing Separate Returns on page 2.
Are you considered unmarried under
that rule?
❏

Yes. Enter your earned income
(from line 17) on line 18. On
line 22, enter $5,000.

❏

No. Enter your spouse’s earned
income on line 18. If your spouse
was a student or disabled in 2005,
see the instructions for line 5. On
line 22, enter $2,500.

-4-

Line 23
Include your deductible benefits in the
total entered on Schedule C, line 14;
Schedule E, line 18 or line 28; or
Schedule F, line 17; whichever
applies.
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confidential, as required by Internal
Revenue Code section 6103.
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required to complete and file this form
will vary depending on individual
circumstances. For the estimated
averages, see the instructions for
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