Form PIT-CG Caregiver's Statement

PART I QUALIFICATIONS FOR INDIVIDUAL CAREGIVERS PART II STATEMENT OF COMPENSATION RECEIVED BY CAREGIVER 1 Were you as a caregiver age eighteen (18) or over at the time the care was performed? 2 Did you as a caregiver provide day care service for less than 24 hours daily? 3 Were you a dependent of the above taxpayer for whom you provided child care services? YES NO YES NO YES NO 2012 PIT CG NEW MEXICO CAREGIVER'S STATEMENT APRIL AUGUST Caregiver's name Address New Mexico CRS ID or social security number Caregiver's signature Caregiver's phone number CHILD 1 Name and SSN CHILD 2 Name and SSN CHILD 3 Name and SSN CHILD 4 Name and SSN 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 DECEMBER 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 FEBRUARY 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 JANUARY MARCH Month No of Days Compensation Amount Received Per Month No of Days Compensation Amount Received Per Month No of Days Compensation Amount Received Per Month No of Days Compensation Amount Received Per Month name and address of the caregiver and explain below why the caregiver did not complete the statement NOVEMBER OCTOBER PART III TAXPAYER: IF YOU COULD NOT OBTAIN A STATEMENT FROM CAREGIVER COMPLETE THIS PORTION OF THE FORM REV 4/27/2012 security number The statement must be signed by the caregiver SEPTEMBER Taxpayer's signature The caregiver must furnish the information on the number of days of care provided each month and the compensation received for each 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 TOTAL