Form 2441
Additional Form 2441 Information Statement                                           2013
Line 1 and 2
G
 Attach to return (after all IRS forms)
Name(s) shown on return
Your social security number
Additional Persons or Organizations Who Provided Care
(a)
 Care provider's 
(b) 
Address
(c) 
Identifying 
(d) 
Amount paid
name                              (number, street, apt. no., city, state, and ZIP Code)        number       (see instructions)
(SSN above
or EIN below)
Last or Business
First                                                               Address
Last or Business
City                            State         ZIP
First                                                               Address
Last or Business
City                            State         ZIP
First                                                               Address
Last or Business
City                            State         ZIP
First                                                               Address
Last or Business
City                            State         ZIP
First                                                               Address
Last or Business
City                            State         ZIP
Total. Enter on an available line on Form 2441 line 1.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 
Additional Qualifying Persons and Expenses
(c) Qualified expenses
 
you 
(a)
 Qualifying person's name 
(b)
 Qualifying person's        incurred and paid in 2013 for 
First                                             Last                            social security number         the person listed in column (a)
Total. Enter on an available line on Form 2441 line 2.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 
First
Address
City
State
ZIP
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