Form  W-10                          Dependent Care Provider’s Identification and Certification 
(Rev. October 2020)                        ▶ Do NOT file Form W-10 with your tax return. Instead, keep it for your records. 
Department of the Treasury  
Internal Revenue Service                               ▶ Go to www.irs.gov/FormW10 for the latest information.
Part I       Dependent Care Provider’s Identification (see instructions) 
         Name of dependent care provider                                                       Provider’s taxpayer identification number 
Please 
Print    Address (number, street, and apt. no.)                                                If  the  above  number  is  a  social  security 
or                                                                                             number, check here  ▶  .       .  .   . . .
Type     City, state, and ZIP code 

Certification and Signature of Dependent Care Provider.         Under penalties of perjury, I, as the dependent care provider, certify that my 
name, address, and taxpayer identification number shown above are correct. 
Please   Dependent care provider’s signature                                                   Date 
Sign 
Here
Part II      Name and Address of Person Requesting Part I Information (see instructions) 
Name, street address, apt. no., city, state, and ZIP code of person requesting information 

General Instructions                                                     • If the provider is your household employee and he or she gave  
                                                                         you a properly completed Form W-4, Employee’s Withholding  
Section references are to the Internal Revenue Code.                     Certificate, to have income tax withheld, a copy of that  Form W-4. 
Purpose of form. You must get the information shown in Part I            If your care provider doesn’t comply with your request for one of 
from each person or organization that provides care for your child or    these items, you must still report certain information on your Form 
other dependent if:                                                      2441. For details, see the Instructions for Form 2441. 
   1. You plan to claim a credit for child and dependent care  
expenses on Form 1040 or 1040-SR, or                                     Specific Instructions 
   2. You receive benefits under your employer’s dependent care  
plan.                                                                    Part I 
   If either 1 or 2 above applies, you must show the correct name,       The individual or organization providing the care completes this  
address, and taxpayer identification number (TIN) of each care           part. 
provider on Form 2441, Child and Dependent Care Expenses.                Enter the provider’s name, address, and TIN. For individuals and 
   You may use Form W-10 or any of the other sources listed under        sole proprietors, the TIN is a social security number (SSN). But if the 
Due diligence below to get this information from each provider.          provider is a nonresident or resident alien who doesn’t have and 
                                                                         isn’t eligible to get an SSN, the TIN is an IRS individual taxpayer 
Penalty for failure to furnish TIN.TINs are needed to carry outthe       identification number (ITIN). For other entities, it is the employer 
Internal Revenue laws of the United States. Section 6109(a)              identification number (EIN). If the provider is exempt from federal 
requires a provider of dependent care services to give to you a          income tax as an organization described in section 501(c)(3), see 
valid TIN, even if the provider isn’t required to file a return. The IRS Tax-exempt dependent care provider below. 
uses the TIN to identify the provider and verify the accuracyof the 
provider’s return as well as yours.                                      How to get a TIN.Providers who don’t have a TIN should applyfor 
                                                                         one immediately. To apply for an SSN, get Form SS-5,Application 
   A care provider who doesn’t give you a correct TIN is subject to a    for a Social Security Card, from your local Social Security 
penalty for each failure unless the failure is due to reasonable cause   Administration office. To apply for an ITIN, get Form W-7,  
and not willful neglect. This penalty doesn’t apply to an organization   Application for IRS Individual Taxpayer Identification Number,from 
described in section 501(c)(3). See Tax-exempt dependent care            the IRS. To apply for an EIN, get Form SS-4, Application for  
provider, later.                                                         Employer Identification Number, from the IRS. 
If incorrect information is reported. You won’t be allowed thetax        Note: An ITIN is for tax use only, and may expire under certain 
credit or the exclusion for employer-provided dependent care             conditions. It doesn’t entitle the individual to social security benefits 
benefits if:                                                             or change his or her employment or immigration status under U.S. 
• You report an incorrect name, address, or TIN of the provider on       law. For details, see the Instructions for Form W-7. 
your Form 2441; and                                                      Tax-exempt dependent care provider. A provider who is a tax-
• You can’t establish, to the IRS upon its request, that you used        exempt organization described in section 501(c)(3) andexempt 
due diligence in trying to get the required information.                 under section 501(a) isn’t required to supply its TIN. Instead, the 
Due diligence. You can show due diligence by getting and keeping         provider must complete the name and address lines and write “tax-
in your records any one of the following.                                exempt” in the space for the TIN. Generally, anexempt       501(c)(3) 
                                                                         organization is one organized and operated exclusively for religious, 
• A Form W-10 properly completed by the provider.                        charitable, scientific, testing for public safety, literary, or educational 
• A copy of the provider’s social security card.                         purposes, or for the prevention of cruelty to children or animals. 
• A recently printed letterhead or printed invoice that shows the  
provider’s name, address, and TIN.                                       Part II 
• If the provider is your employer’s dependent care plan, a copy of      Complete this part only if you are leaving the form with the  
the statement provided by your employer under the plan.                  dependent care provider to return to you later. 

                                                                 Cat. No. 10437N                                    Form  W-10  (Rev. 10-2020)