Form 2441 Child and Dependent Care Expenses. Summary: This is a sample Form 2441 (2005), Page 1 pertaining to the example explained in the text, with additional line item information not listed in the text.

Name(s) shown on Form 1040 field contains Joan Thomas

Your social security number field contains 559-00-3436

Under Part I: Persons or Organizations Who Provided the Care:

1(a) Care provider's name field contains Pat Green and ACME Computers

1(b) Address (number, street, apartment number, city, state, and ZIP code) field contains 12 Ash Avenue, Hometown, Texas 75240 and (See W-2)

1(c) Identifying number (Social Security Number or Employer Identification Number) field contains 240-00-3811

1(d) Amount paid (see instructions) field contains 2,400

Under Part II: Credit for Child and Dependent Care Expenses:

2(a) Qualifying person's name: First field contains Seth and Susan

2(a) Qualifying person's name: Last field contains Thomas and Thomas

2(b) Qualifying person's social security number field contains 559-00-1234 and 559-00-5678

2(c) Qualified expenses you incurred and paid in 2005 for the person listed in column (a) field contains 2,400

3. 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 26 field contains 2,400

4. Enter your earned income field contains 29,000

5. 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 field contains 29,000

6. Enter the smallest of line 3, 4, or 5 field contains 2,400

7. Enter the amount from Form 1040, line 38 field contains 29,000

8. Enter on line 8 the decimal point shown below that applies to the amount on line 7 field contains .28

9. Multiply line 6 by the decimal amount on line 8. If you paid 2004 expenses in 2005, see the instructions field contains 672

10. Enter the amount from Form 1040, line 46, minus any amount on Form 1040, line 47 field contains 1,296

11. Credit for child and dependent care expenses. Enter the smaller of line 9 or line 10 here and on Form 1040, line 48 field contains 672