Child and Dependent Care Expenses

Your Email Address (required)... Taxpayer Social Security No.

Care Provider 1		Care Provider 2
	Name	Name
	Address	Address
	City, ST, Zip	City, ST, Zip
	Identifying Number	Identifying Number
	Amount Paid	Amount Paid
Qualifying Person 1		Qualifying Person 2
	First Name	First Name
	Last Name	Last Name
	Social Security Number	Social Security Number
	Qualifying Expenses Paid in 2005	Qualifying Expenses Paid in 2005
	Did you receive dependent care benefits from your employer? No Yes
	If "Yes", Enter amount from box 10 on your W-2
	Enter amount forfeited or carried over to 2006, if any