Form 2441Additional Form 2441 Information Statement                                           2013

Line 1 and 2G Attach to return (after all IRS forms)

Name(s) shown on returnYour 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 BusinessCity                            State         ZIP

First                                                               Address

Last or BusinessCity                            State         ZIP

First                                                               Address

Last or BusinessCity                            State         ZIP

First                                                               Address

Last or BusinessCity                            State         ZIP

First                                                               Address

Last or BusinessCity                            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.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

FirstAddress

CityStateZIP

----------------Page (0) Break----------------