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Click ‘Get Form’ to open it in the editor.
Begin by entering the taxpayer's name(s) and Letter ID at the top of the form. If you don't have a Letter ID, input your Social Security Number instead.
Fill in the date range for the care provided, specifying both start and end dates.
In the provider section, enter your name along with your Social Security Number (SSN), Individual Tax Identification Number (ITIN), or Federal Employer Identification Number (FEIN).
List each dependent's name and age, along with total payments received from the taxpayer for each dependent. Include any payments received from third parties as applicable.
Complete the additional questions regarding payment frequency and methods. Ensure to provide accurate details about receipts issued for payments.
Sign and date the form at the bottom, confirming that all information is true and complete before submitting it back to the taxpayer or directly to the department.
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