(Rev. October 2016)
Department of the Treasury
Internal Revenue Service
Dependent Care Provider’s Identification and Certification
Do NOT file Form W-10 with your tax return. Instead, keep it for your records.
Information about Form W-10 and its instructions is at www.irs.gov/formw10.
Part I Dependent Care Provider’s Identification (See instructions.)
Name of dependent care provider
Address (number, street, and apt. no.)
City, state, and ZIP code
Provider’s taxpayer identification number
If the above number is a social security
number, check here
Certification and Signature of Dependent Care Provider. Under penalties of perjury, I, as the dependent care provider, certify that my
name, address, and taxpayer identification number shown above are correct.
Dependent care provider’s signature Date
Part II Name and Address of Person Requesting Part I Information (See instructions.)
Name, street address, apt. no., city, state, and ZIP code of person requesting information
Section references are to the Internal Revenue Code.
Purpose of form. You must get the information shown in Part I
from each person or organization that provides care for your child or
other dependent if:
1. You plan to claim a credit for child and dependent care
expenses on Form 1040 or 1040A, or
2. You receive benefits under your employer’s dependent care
If either 1 or 2 above applies, you must show the correct name,
address, and taxpayer identification number (TIN) of each care
provider on Form 2441, Child and Dependent Care Expenses.
You may use Form W-10 or any of the other sources listed under
Due diligence below to get this information from each provider.
Penalty for failure to furnish TIN. TINs are needed to carry outthe
Internal Revenue laws of the United States. Section 6109(a)
requires a provider of dependent care services to give to you a
valid TIN, even if the provider isn't required to file a return. The IRS
uses the TIN to identify the provider and verify the accuracyof the
provider’s return as well as yours.
A care provider who doesn't give you a correct TIN is subject to a
penalty for each failure unless the failure is due to reasonable cause
and not willful neglect. This penalty doesn't apply to an organization
described in section 501(c)(3). See Tax-exempt dependent care
If incorrect information is reported. You won't be allowed thetax
credit or the exclusion for employer-provided dependent care
• You report an incorrect name, address, or TIN of the provider on
your Form 2441, and
• You can't establish, to the IRS upon its request, that you used
due diligence in trying to get the required information.
Due diligence. You can show due diligence by getting and keeping
in your records any one of the following.
• A Form W-10 properly completed by the provider.
• A copy of the provider’s social security card or driver’s license
that includes his or her social security number.
• A recently printed letterhead or printed invoice that shows the
provider’s name, address, and TIN.
• If the provider is your employer’s dependent care plan, a copy of
the statement provided by your employer under the plan.
• If the provider is your household employee and he or she gave
you a properly completed Form W-4, Employee’s Withholding
Allowance Certificate, to have income tax withheld, a copy of that
If your care provider doesn't comply with your request for one of
these items, you must still report certain information on your Form
2441. For details, see the Form 2441 instructions.
The individual or organization providing the care completes this
Enter the provider’s name, address, and TIN. For individuals and
sole proprietors, the TIN is a social security number (SSN). But if the
provider is a nonresident or resident alien who doesn't have and
isn't eligible to get an SSN, the TIN is an IRS individual taxpayer
identification number (ITIN). For other entities, it is the employer
identification number (EIN). If the provider is exempt from federal
income tax as an organization described in section 501(c)(3), see
Tax-exempt dependent care provider below.
How to get a TIN. Providers who don't have a TIN should applyfor
one immediately. To apply for an SSN, get Form SS-5,Application
for a Social Security Card, from your local Social Security
Administration office. To apply for an ITIN, get Form W-7,
Application for IRS Individual Taxpayer Identification Number,from
the IRS. To apply for an EIN, get Form SS-4, Application for
Employer Identification Number, from the IRS.
Note: An ITIN is for tax use only, and may expire under certain
conditions. It doesn't entitle the individual to social security benefits
or change his or her employment or immigration status under U.S.
law. For details, see the Form W-7 instructions.
Tax-exempt dependent care provider. A provider who is a tax-
exempt organization described in section 501(c)(3) andexempt
under section 501(a) isn't required to supply its TIN. Instead, the
provider must complete the name and address lines and write “tax-
exempt” in the space for the TIN. Generally, anexempt 501(c)(3)
organization is one organized and operated exclusively for religious,
charitable, scientific, testing for public safety, literary, or educational
purposes, or for the prevention of cruelty to children or animals.
Complete this part only if you are leaving the form with the
dependent care provider to return to you later.
Cat. No. 10437N
W-10 (Rev. 10-2016)