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SUPPORTING DOCUMENTS
886-A
Form
Page
(August 1999)
Taxpayers Name
Social Security Number
Tax Period Ending
First M & First M Last
XXX-XX-XXXX
December 31, 2011
You will need to substantiate each claimed deduction. The supporting documents on each item must be
complete enough for us to make a fair determination. Send only photocopies of all documents used for
verification. DO NOT SEND ORIGINALS.
S C H E D U L E A - I T E M I Z E D D E D U C T I O N S :
M E D I C A L A N D D E N TA L E X P E N S E S
1.
Send copies of cancelled checks, receipts or statements for all medical savings accounts, medical and
dental expenses (including medical insurance) showing the person for whom each expense was incurred,
along with any insurance or employer reimbursement records. Send a copy of your medical insurance
handbook or policy describing the benefits and reimbursement policy and verification of premium cost.
2.
For prescription drug expenses, send copies of statements or receipts showing the prescription numbers,
names of drug, cost and date purchased.
3.
For other expenses (including equipment, capital improvements, transportation and lodging) send proof of
payment and statements to show cost and medical requirement. For capital improvements, send an
appraisal from a qualified estimator or adjustor showing the fair market value of the property before and after
the improvements.
C H I L D A N D D E P E N D E N T C A R E C R E D I T
Generally, you can claim the credit if the following tests are met:
1. The care must be for one or more qualifying persons.
2. You must keep up a home that you live in with the qualifying person(s).
3. You must have earned income during the year.
4. You must pay child and dependent care expenses so you (and your spouse if married filing jointly) can work
or look for work. Special rules apply if you or your spouse was a full-time student or disabled.
5. Your care provider cannot be someone whom you can claim as a dependent.
6. Your filing status cannot be married filing separate.
7. You must include your care provider’s identification number.
Acceptable documentation:
1.
Copies of receipts and canceled checks for childcare expenses you paid for in the tax year in question.
2. A letter from your childcare provider. The letter should include the name, address and identification number
of your childcare provider and should include the total amount you paid for child care in the tax year in
question.
3. A statement from your employer that includes the amount, if any, of qualified child care expenses provided to
you by your employer in the tax year in question.
4 . Copies of documents to verify the child and dependent care expenses were paid so you (and your spouse if
married filing jointly) could work or look for work. Acceptable documentation can include a letter from your
employer including an explanation of your job and work schedule, copies of interview sheets/statements from
jobs applied to or similar records. If you (or your spouse) were a full-time student or disabled send copies of
school transcripts or a letter from the school showing full-time course load and courses enrolled in, including
the number of months you were in school or a letter from a doctor verifying the nature of your disability and
when you became disabled.
886-A
Form
Service
Department of the Treasury – Internal Revenue
(August 1999)