Form Pit-Cg - New Mexico Caregiver'S Statement - 2013
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1Rev. 6/18/2013
2013 PIT-CG
NEW MEXICO CAREGIVER'S STATEMENT
This schedule must be completed by the caregiver and given to the taxpayer to be attached to the PIT-1 return and Schedule PIT-RC. Each
caregiver who provided day care services for which a credit amount is claimed completes a separate PIT-CG. Failure to attach the required
PIT-CG to the PIT-1 return causes the amount claimed for the child day care credit to be disallowed. Attach the Child Day Care Credit Work-
sheet to the PIT-CG.
The caregiver must furnish the information on the number of days of care was provided each month and the compensation received for
each child for whom the credit is being claimed. The three qualification questions must be completed and the name, address, phone number
and New Mexico CRS identification number of the caregiver provided. For each child receiving day care services, provide the name and
social security number. The statement must be signed by the caregiver.
Do not include any charges for child care for periods of unemployment or for child care provided either before or after work (plus any neces-
sary travel time) or for periods a taxpayer is attending school.
Last name
Taxpayer's social security number
Taxpayer's first name and initial (as it appears on Form PIT-1)
PART I. QUALIFICATIONS FOR INDIVIDUAL CAREGIVERS
Caregiver's name
New Mexico CRS ID or social security
Address
number
1. Were you, as a caregiver, age 18 or over at the time the care was performed?
NO
YES
2. Did you, as a caregiver, provide day care service for less than 24 hours daily?
YES
NO
3. Were you a dependent of the above taxpayer for whom you provided child care services?
NO
YES
PART II. STATEMENT OF COMPENSATION RECEIVED BY CAREGIVER
CHILD 1 Name and SSN
CHILD 2 Name and SSN
CHILD 3 Name and SSN
CHILD 4 Name and SSN
Compensation
Compensation
Compensation
Compensation
No. of
No. of
No. of
No. of
Amount Received
Amount Received
Amount Received
Amount Received
Month
Days
Days
Days
Days
Per Month
Per Month
Per Month
Per Month
JANUARY
FEBRUARY
MARCH
APRIL
MAY
JUNE
JULY
AUGUST
SEPTEMBER
OCTOBER
NOVEMBER
DECEMBER
TOTAL
Caregiver's signature _____________________________________
Caregiver's phone number __________________ __________
PART III. TAXPAYER: IF YOU COULD NOT OBTAIN A STATEMENT FROM CAREGIVER, COMPLETE THIS PORTION OF THE FORM.
f all reasonable attempts to complete this schedule have been made, and the taxpayer is still unable to locate the caregiver or to obtain
I
the required information, the taxpayer completes Parts I and II of this schedule based on previous billings or other records, provides the
name and address of the caregiver, and explains below why the caregiver did not complete the statement.
Taxpayer's signature ___________________________________________
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