Form Pit-Cg - New Mexico Caregiver'S Statement
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1REV. 4/27/2012
2012 PIT-CG
NEW MEXICO CAREGIVER'S STATEMENT
This schedule must be completed by the caregiver and given to the taxpayer to be attached to Form PIT-1 and Schedule PIT-RC. A separate
PIT-CG should be completed by each caregiver who provided day care services for which a credit amount is being claimed. Failure to attach
the required PIT-CG to the Form PIT-1 will cause the amount claimed for the child day care credit to be disallowed.The Child Day Care Credit
Worksheet should be attached to the PIT-CG.
The caregiver must furnish the information on the number of days of care 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.
Taxpayer's social security number
Taxpayer's first name & initial (as it appears on Form PIT-1)
Last name
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 eighteen (18) or over at the time the care was performed?
YES
NO
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
Month
Amount Received
Amount Received
Amount Received
Amount Received
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.
If all reasonable attempts to complete this schedule have been made, and the taxpayer is still unable to locate the caregiver or to obtain
the required information, the taxpayer should complete Part 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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