Additional Schedule WFC Information Statement
Attach to your return
Statement
Name(s) shown on return
Social Security number (SSN)
Additional Qualifying Providers Information - complete all information for each provider
Child to Provider
Name
City, State, ZIP code
. . . . . . . . 
$
Name
City, State, ZIP code
. . . . . . . . 
$
Name
City, State, ZIP code
. . . . . . . . 
$
Name
City, State, ZIP code
. . . . . . . . 
$
Name
City, State, ZIP code
. . . . . . . . 
$
Name
City, State, ZIP code
.
. . . . . . . . 
$
Total.
 Enter the total amount on Schedule WFC line 9
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 
$
Additional Qualifying Children Information
- Complete all information for each child
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Total.
 Enter the total amount on Schedule WFC line 14
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 
$
2013
Provider's full name and complete address
Provider's full name and complete address
Provider's full name and complete address
Provider's SSN or
Provider's full name and complete address
Provider's full name and complete address
Provider's full name and complete address
Provider's FEIN
Address
Provider's Telephone No.
Address
Provider's Telephone No.
Address
Provider's Telephone No.
Address
Provider's Telephone No.
Address
Provider's Telephone No.
Address
Provider's Telephone No.
Amount You Paid to Provider
Child to Provider
Amount You Paid to Provider
Child to Provider
Amount You Paid to Provider
Child to Provider
Amount You Paid to Provider
Child to Provider
Amount You Paid to Provider
Child to Provider
Amount You Paid to Provider
Provider's SSN or
Provider's FEIN
Provider's SSN or
Provider's FEIN
Provider's SSN or
Provider's FEIN
Provider's SSN or
Provider's FEIN
Provider's SSN or
Provider's FEIN
Relationship
Relationship
Relationship
Relationship
Relationship
Relationship
First and Last Name of Child
Child's SSN
Date of Birth
You Paid for Child
Child's
Relationship
Expenses
Child toTaxpayer
Qualifying
----------------Page (0) Break----------------