Form It-216 - Claim For Child And Dependent Care Credit - 2012
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1
2IT-216
New York State Department of Taxation and Finance
Claim for Child and Dependent Care Credit
New York State • New York City
Submit this form with Form IT-201 or IT-203.
Name(s) as shown on return
Your social security number
1 Have you already filed your New York State income tax return? ................................ Yes
No
If Yes, you must file an amended New York State return and include
Form IT-216 to claim this credit.
2 Persons or organizations who provided the care.
(If you have more than two providers, see instructions.)
A – Care provider’s first name,
B – Address
C – Identifying number
D – Amount paid
middle initial, and last name
(SSN or EIN)
(see instructions)
.
00
.
00
3 Qualifying persons you are claiming. List in order from youngest to oldest.
...............................................
(If you are claiming more than four qualifying persons, mark an X in the box and see instructions.)
A – First name and
B – Last name
C – Qualified
D – Person
E – Social security number
F – Date of birth
middle initial
expenses paid
with
(mm-dd-yyyy)
disability
(see instr.)
.
00
.
00
.
00
.
00
Note: If you are claiming expenses paid for a dependent child, include only those qualified expenses paid through the day preceding the
child’s 13th birthday.
.
3a Total of line 3, column C amounts. Include amounts from additional sheet(s), if any ............................ 3a
00
4 Can you claim an exemption for all the qualified persons listed on line 3 and any additional sheet(s)?...................... Yes
No
5 Enter the smallest of:
– line 3a above; or
Whole dollars only
– federal Form 2441, line 3; or
.
5
– 3,000 if one qualifying person, or 6,000 if two or more qualifying persons ......................................
00
.
6 Enter your earned income
............................................................................................
6
00
(see instructions)
7 If your filing status is Married filing joint return, enter your spouse’s earned income;
.
all others, enter the amount from line 6
....................................................................
7
00
(see instructions)
.
8 Enter the smallest of line 5, 6, or 7 .........................................................................................................
8
00
9 Enter the amount from: federal Form 1040A, line 22,
.
or federal Form 1040, line 38 ................................................
9
00
10 Enter the decimal amount that applies to the amount
on line 9 from the Table for line 10 in the instructions ....................................................................... 10
.
11 Multiply line 8 by the decimal amount on line 10
...........................
11
00
(enter here and on line 12 on the back)
216001120094
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