Fillable Printable Form Or-Ps, Care Provider Statement, 150-101-190

Form Or-Ps, Care Provider Statement, 150-101-190

Taxpayer name(s): _________________________________________________________

Letter ID: __________________

Date from: _________________ Date to: _________________

Complete this form for care you provided for the taxpayer(s) during the dates above.

Provider’s name:

Provider’s SSN or FEIN: _

Dependent’s first name Dependent’s last name

Dependent’s

age

Total payment

received for this

dependent

Total payments

received from a

third party*

Total payments you

received from the

taxpayer(s)

$ $ $

Total $ $ $

* Department of Human Services, another individual, etc.

1. Did you provide care for dependent’s not associated with the taxpayer(s) listed above? Yes No

2. How often were you paid?

Monthly Weekly Biweekly Other (please explain)

3. How were you paid?

Cash Check Money order Electronic payment Other (please explain)

4. Did you provide the taxpayer with a receipt every time you were paid?

Yes No If no, please explain

5. Please provide the following information on all of the dependents listed above:

• A detailed year-end summary;

• The typical days and times in your care;

• The total hours per month in your care;

• The amounts you were paid, with the dates those

payments were made; and

• Your rate, late fees charged, and any refunds or

discounts given to the taxpayer.

6. If you are an individual operating outside of a facility, provide a copy of the front and back of your driver license or other government-issued ID.

Provider declaration

Under penalties of false swearing, I declare that the information I have provided is, to the best of my knowledge and belief, true,

correct, and complete.

I understand that the above income is considered taxable income. If I filed a return and didn’t include this income, my return may be

adjusted. I also understand that if I didn’t file a return, a Notice of Assessment may be issued for failing to file.

Printed name Facility name

Signature Date

Address where services are provided Daytime phone

18310001010000

— Return the completed form and supporting documentation to the taxpayer. —

If you’d like to submit this information directly to us, you can fax the completed information or mail it to us, with a copy to the taxpayer for their records.

Fax: Mail:

Attn: Suspense Oregon Department of Revenue

(503) 345-2354 Attn: Suspense

PO Box 14999

Salem OR 97309-0090

Oregon Department of Revenue

2016 Form OR-PS

Care Provider Statement

Submit original form—do not submit photocopy.

Office use only

Page 1 of 1, 150-101-190 (Rev. 10-16)

150-101-190 (Rev. 10-16)

Introduction

The Care Provider Statement is used to meet record keep-

ing requirements for the Working Family Child Care (WFC)

credit and the Working Family Household and Dependent

Care (WFHDC) credit. The statement lists detailed infor-

mation regarding the care that was provided for the tax-

payer’s dependents.

The Care Provider Statement is commonly requested by the

department when the WFC or WFHDC credit is claimed. If

requested, the statement will be mailed to the taxpayer to

complete; however, if the statement is lost or not received,

taxpayers may request their provider fill out the statement

available on our website.

Instructions for taxpayers

Enter your and your spouse’s name (if married filing jointly).

Enter the Letter ID from the letter you received from us

requesting the Care Provider Statement. The Letter ID can

be found on the top of the letter; it’s an 11 digit code starting

with “L.” If you don’t have a Letter ID, write your (and your

spouse’s) Social Security number on the line instead.

Enter the beginning and ending date of the tax year you

claimed the credit and that your qualifying individual was

in your provider’s care. Generally, this will be January 1

and December 31 of the corresponding tax year.

If you have more than one provider, fill out a separate Care

Provider Statement for each provider.

Give the Care Provider Statement to your provider to com-

plete. Either your provider will return the original to you

to submit to us, or they will submit the statement to us and

give you a copy. If your provider sends us the completed

Care Provider Statement, keep the copy for your records.

You have 30 days to return the statement to the depart-

ment once it has been requested.

If your provider filled out the statement and returned it to

you, submit it to the department with any other supporting

documentation we requested.

If you can’t obtain a statement from your provider, you may sub-

mit proof of payments, receipts for those payments, and a letter

explaining why you couldn’t obtain the Care Provider Statement.

Acceptable proof of payment:

• Cancelled check (front and back).

• Money order stub, along with a corresponding bank statement.

• Cashier’s check, along with a cooresponding bank statement.

• Duplicate check, with a corresponding bank statement.

• Bank statements showing cash withdrawals.

Instructions for Care Provider Statement

Receipts must be received at the time of payment, must

match the proof of payment, and must include:

• Qualifying individual’s full name.

• Date of care.

• Date and amount paid.

• Name of person or agency paying.

• Provider’s name, address, and phone number.

• Provider’s Social Security number (SSN) or federal

employer identification number (FEIN).

• Method of payment (check, money order, cash, etc.).

Letter:

• Provide the following information about your provider:

o Name.

o Tax identication number (Social Security number,

federal employer identication number, or individual

tax identication number).

o Phone number.

o Address.

• Explain why your provider was unable to complete the

Care Provider Statement. We may contact your pro-

vider to verify the information.

Instructions for care providers

Enter your name and SSN or FEIN. Complete all subse-

quent lines on the statement.

If you provided care for more than four of the taxpayer’s

dependents, complete additional forms as needed.

Once you have completed the statement, return it and the

supporting documentation to the taxpayer as soon as pos-

sible. They will submit the information to the department

once it has been requested.

You may also send the statement to the department directly.

To submit it to us, fax the completed information to (503)

345-2354, labeled “Attn: Suspense,” or mail it to:

Oregon Department of Revenue

Attn: Suspense

PO Box 14999

Salem OR 97309-0090

If you send the information directly to us, provide the tax-

payer with a copy for their records.

Do you have questions or need help?

www.oregon.gov/dor

(503) 378-4988 or 1 (800) 356-4222

questions.dor@oregon.gov

languages.