Form Pit-Cg - New Mexico Caregiver'S Statement - 2016
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1Rev. 09/13/2016
PIT-CG
NEW MEXICO CAREGIVER'S STATEMENT
The caregiver must complete this PIT-CG and give it to the taxpayer to attach to the PIT-1 Return and Schedule PIT-RC. Each caregiver who
provides daycare services for which a credit amount is claimed completes a separate PIT-CG. Failure to attach the required PIT-CG to the
PIT-1 will cause the amount claimed for the child daycare credit to be disallowed. Attach the Child Day Care Credit Worksheet to the PIT-CG.
The caregiver must furnish the information on the number of days care was provided each month and the compensation received for
each child for whom the credit is claimed. The caregiver must answer the three qualification questions; enter their name, address, phone
number, and New Mexico CRS identification number; and sign this PIT-CG. The name and social security number for each child receiving
daycare services is required on this PIT-CG. The taxpayer must also sign.
Do not include any charges for childcare for periods of unemployment or for childcare provided either before or after work (plus any necessary
travel time) or for periods the taxpayer is attending school.
Taxpayer's 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
Caregiver's address
Caregiver's New Mexico CRS ID or SSN
1. Were you, as a caregiver, age 18 or over at the time the care was performed?
YES
NO
2. Did you, as a caregiver, provide daycare service for less than 24 hours daily?
YES
NO
3. Were you a dependent of the above taxpayer for whom you provided childcare 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
TAX YEAR
20___
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 THE CAREGIVER, COMPLETE THIS PART OF THE FORM.
f you made all reasonable attempts to complete this PIT-CG schedule, and you are still unable to locate the caregiver or to obtain the
I
required information, complete Parts I and II of this schedule based on previous billings or other records, provide the name and address
of the caregiver, and explain below why the caregiver did not complete the statement.
Taxpayer's signature ___________________________________________
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