Additional Schedule WFC Information Statement

Attach to your returnStatement

Name(s) shown on returnSocial Security number (SSN)

Additional Qualifying Providers Information - complete all information for each providerChild 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 addressProvider'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

AddressProvider's Telephone No.

AddressProvider's Telephone No.

AddressProvider's Telephone No.

AddressProvider's Telephone No.

AddressProvider's Telephone No.

AddressProvider'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 orProvider's FEIN

Provider's SSN orProvider's FEIN

Provider's SSN orProvider's FEIN

Provider's SSN orProvider's FEIN

Provider's SSN orProvider's FEIN

Relationship

Relationship

Relationship

Relationship

Relationship

Relationship

First and Last Name of ChildChild's SSNDate of BirthYou Paid for Child

Child's

Relationship

ExpensesChild toTaxpayer

Qualifying

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