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