Form W-10
(Rev. August 1996)
Dependent Care Provider’s Identification and Certification
Department of the Treasury
Internal Revenue Service
Dependent Care Provider’s Identification (See instructions.)
Name of dependent care provider Provider’s taxpayer identification number
Address (number, street, and apt. no.)
If the above number is a social security
number, check here
City, state, and ZIP code
Certification and Signature of Dependent Care Provider.—Under penalties of perjury, I, as the dependent care provider, certify
that my name, address, and taxpayer identification number shown above are correct.
DateDependent care provider’s signature
Name and Address of Person Requesting Part I Information (See instructions.)
Name, street address, apt. no., city, state, and ZIP code of person requesting information
Enter the provider’s name, address, and TIN. For individuals
and sole proprietors, the TIN is a social security number (SSN).
But if the provider is a nonresident or resident alien who does
not have and is not eligible to get an SSN, the TIN is an IRS
individual taxpayer identification number (ITIN). For other entities,
it is the employer identification number. If the provider is exempt
from Federal income tax as an organization described in section
501(c)(3), see Tax-exempt dependent care provider below.
General Instructions
If incorrect information is reported.—You will not be allowed
the tax credit or the exclusion for employer-provided dependent
care benefits if:
You report an incorrect name, address, or TIN of the provider
on your Form 2441 or Schedule 2, and
You cannot establish, to the IRS upon its request, that you
used due diligence in trying to get the required information.
How to get a TIN.—Providers who do not have a TIN should
apply for one immediately. To apply for an SSN, get Form SS-5,
Application for a Social Security Card, from your local Social
Security Administration office. To apply for an ITIN, get Form
W-7, Application for IRS Individual Taxpayer Identification
Number, from the IRS. To apply for an EIN, get Form SS-4,
Application for Employer Identification Number, from the IRS.
Due diligence.—You can show due diligence by getting and
keeping in your records any one of the following:
A Form W-10 properly completed by the provider.
A copy of the provider’s social security card or driver’s license
that includes his or her social security number.
A recently printed letterhead or printed invoice that shows the
provider’s name, address, and TIN.
If the provider is your employer’s dependent care plan, a copy
of the statement provided by your employer under the plan.
Penalty for failure to furnish TIN.—TINs are needed to carry
out the Internal Revenue laws of the United States. Section
6109(a) requires a provider of dependent care services to give to
you a valid TIN, even if the provider is not required to file a
return. The IRS uses the TIN to identify the provider and verify
the accuracy of the provider’s return as well as yours.
Income tax reporting requirements for dependent care
providers.—The individual provider must report on his or her
income tax return all income received for providing care for any
person. If the provider is a self-employed individual, the income
is reported on Schedule C or C-EZ (Form 1040), whichever
Part I
Part II
The individual or organization providing the care completes this
Form W-10 (Rev. 8-96)
Do NOT file Form W-10 with your tax return. Instead, keep it for your records.
Section references are to the Internal Revenue Code.
Part I
Part II
Purpose of form.—You must get the information shown in
Part I from each person or organization that provides care for
your child or other dependent if:
If your care provider does not comply with your request for
one of these items, you must still report certain information on
your Form 2441 or Schedule 2, whichever applies. For details,
see the Form 2441 or Schedule 2 instructions.
Tax-exempt dependent care provider.—A provider who is a
tax-exempt organization described in section 501(c)(3) and
exempt under section 501(a) is not required to supply its TIN.
Instead, the provider must complete the name and address lines
and write “tax-exempt” in the space for the TIN. Generally, an
exempt 501(c)(3) organization is one organized and operated
exclusively for religious, charitable, scientific, testing for public
safety, literary, or educational purposes, or for the prevention of
cruelty to children or animals.
Complete this part only if you are leaving the form with the
dependent care provider to return to you later.
If either 1 or 2 above applies, you must show the correct
name, address, and taxpayer identification number (TIN) of each
care provider on Form 2441, Child and Dependent Care
Expenses, or Schedule 2, Child and Dependent Care Expenses
for Form 1040A Filers, whichever applies.
A care provider who does not give you his or her correct TIN
is subject to a penalty of $50 for each failure unless the failure is
due to reasonable cause and not willful neglect. This penalty
does not apply to an organization described in section 501(c)(3).
See Tax-exempt dependent care provider later.
Cat. No. 10437N
1. You plan to claim a credit for child and dependent care
expenses on Form 1040 or 1040A, or
2. You receive benefits under your employer’s dependent care
You may use Form W-10 or any of the other sources listed
under Due diligence below to get this information from each
Specific Instructions
Note: An ITIN is for tax use only. It does not entitle the individual
to social security benefits or change his or her employment or
immigration status under U.S. law.
If the provider is your household employee and he or she gave
you a properly completed Form W-4, Employee’s Withholding
Allowance Certificate, to have income tax withheld, a copy of
that Form W-4.