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5                                                                                                                                  Oregon Department of Revenue                     5
                        2023 Schedule OR-WFHDC-PR
6                       Working Family Household and Dependent Care Credit for Prior Year Expenses                                                                                  6
7                                                                                                                                                                                   7
8                       Page 1 of 4  • Use UPPERCASE letters.  • Use blue or black ink.  • Print actual size (100%).  • Don’t submit photocopies or use staples.                    8
9           Last name                                                                                                           Social Security number (SSN)                        9
10                                                                                                                                                                                  10
11                                                                                                                                                                                  11
            XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                                                                    999-99-9999
12                                                                                                                                                                                  12
13          Instructions: Use this worksheet only if you paid providers in early 2023 for services received toward the end of the year in 2022.                                     13
14          You will need information from your 2022 Oregon return and Schedule OR-WFHDC to complete this worksheet. If you didn’t claim                                            14
15          this credit for tax year 2022, you will need to complete federal Form 2441, Child and Dependent Care Expenses, for 2022 even if you                                     15
16          didn’t claim the federal credit. Keep this worksheet with your tax records.                                                                                             16
17                                                                                                                                                                                  17
18          Section 1—Credit for prior year expenses.                                                                                                                               18
19                                                                                                                                                                                  19
20            1.  Enter your 2022 qualified expenses paid in 2022 .....................................   1.                       ,                         999,999,999.00, 0 0    20
21                                                                                                                                                                                  21
22                                                                                                                                                                                  22
23            2.  Enter your 2022 qualified expenses paid in 2023 .....................................   2.                       ,                         999,999,999.00, 0 0    23
24                                                                                                                                                                                  24
25                                                                                                                                                                                  25
26            3.  Add lines 1 and 2 .......................................................................................   3.   ,                         999,999,999.00, 0 0    26
27                                                                                                                                                                                  27
28                                                                                                                                                                                  28
29            4.  Enter the amount from line 18 of your 2022 Schedule OR-WFHDC .........   4.                                      ,                         999,999,999.00, 0 0    29
30                                                                                                                                                                                  30
31            5.  Enter the smaller of your and your spouse’s 2022 earned income. If you                                                                                            31
32                claimed the WFHDC credit in 2022, this is the smaller of lines 20 and 21                                                                                          32
33                on your 2022 Schedule OR-WFHDC. If you  didn’t claim the credit in                                                                                                33
34                2022, fill out federal Form 2441 for 2022. Use the amounts listed on                                                                                              34
35                lines 4 and 5 (or lines 18 and 19 if lines 4 or 5 are blank). Don’t enter                                                                                         35
36                less than zero.............................................................................................   5. ,                         999,999,999.00, 0 0    36
37                                                                                                                                                                                  37
38                                                                                                                                                                                  38
39            6.  Enter the smallest amount from lines 3, 4, or 5 above..............................   6.                         ,                         999,999,999.00, 0 0    39
40                                                                                                                                                                                  40
41            7.  If you claimed the credit in 2022, enter the amount you claimed on                                                                                                41
42                line 22 of your 2022 Schedule  OR-WFHDC. If you didn’t claim the                                                                                                  42
43                credit in 2022, enter zero ...........................................................................   7.      ,                         999,999,999.00, 0 0    43
44                                                                                                                                                                                  44
45            8.  Line 6 minus line 7.  Enter the result. If zero or less, stop here. You can’t                                                                                     45
46                increase your 2023 credit based on prior year’s expenses.                                                                                                         46
47                If more than zero, continue to line 9 ............................................................8.             ,                         999,999,999.00, 0 0    47
48                                                                                                                                                                                  48
49            9.  Enter your 2022 federal adjusted gross income (2022 Form OR-40,                                                                                                   49
50                line 7; Form OR-40-N or Form OR-40-P, line 29F) ...................................   9.                         ,                         999,999,999.00, 0 0    50
51                                                                                                                                                                                  51
52           10.  Enter your 2022 Oregon adjusted gross income (2022 Form OR-40,                                                                                                    52
53                line 7; Form OR-40-N or Form OR-40-P, line 29S) ...................................10.                           ,                         999,999,999.00, 0 0    53
54                                                                                                                                                                                  54
55                                                                                                                                                                                  55
56           11.  Enter the greater of line 9 or line 10...........................................................11.             ,                         999,999,999.00, 0 0    56
57                                                                                                                                                                                  57
58                                                                                                                                                                                  58
59                                                                                                                                                           Continued on next page 59
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62                                                                                                                                                                                  62
                        150-101-197
63                      (Rev. 09-07-23, ver. 01)                                                                                   18892301010000                                   63
64                                                                                                                                                                                  64
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69                                                                                                                                                                                69
70                                                                                                                                                                                70
71                                                                                                                                           Oregon Department of Revenue         71
                          2023 Schedule OR-WFHDC-PR
72                                                                                                                                                                                72
73                                                                                                                                                                                73
74                        Page 2 of 4  • Use UPPERCASE letters.  • Use blue or black ink.  • Print actual size (100%).  • Don’t submit photocopies or use staples.                74
75                                                                                                                                                                                75
76            12.  Enter your decimal value from line 23 of your 2022 Schedule                                                                                                    76
77                  OR-WFHDC. If you didn’t claim  this credit in 2022, use the online                                                                                            77
78                  calculator for tax year 2022 and enter the decimal value .........................12.                                                          9.99     %     78
79                                                                                                                                                                                79
80            13.  Multiply line 8 by line 12. If you filed a 2022 full-year resident return,                                                                                     80
81                  enter this amount on your  2023 Schedule OR- WFHDC, line 28. If you                                                                                           81
82                  filed a 2022 part- year or nonresident return, continue to line 14 ..............13.                                     , 999,999,999.00,            0 0     82
83                                                                                                                                                                                83
84                                                                                                                                                                                84
85            14.  Enter the decimal value from line 35 of your 2022 Form OR- 40- N or                                                                                            85
86                  Form OR- 40- P ...........................................................................................14.                                  999.9    %     86
87                                                                                                                                                                                87
88            15.  Multiply line 13 by line 14 and enter this amount on your 2023                                                                                                 88
89                  Schedule OR-WFHDC, line 28 ..................................................................15.                         , 999,999,999.00,            0 0     89
90                                                                                                                                                                                90
91                                                                                                                                                                                91
92           Section 2—Providers. Complete all information for each provider you paid in 2023 for expenses incurred in 2022. Only list the                                        92
93           amounts you paid in 2023 that apply to services provided in 2022. If you have more than two providers, use an additional page.                                       93
94                                                                                                                                                                                94
95           16a. Provider first name                      16b. Initial 16c. Provider last name                                                                                   95
96                                                                                                                                                                                96
97                                                                                                                                                                                97
             XXXXXXXXXXXXXXXX                              X       XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
98           16d. Provider business name, if applicable                                                                                                                           98
99                                                                                                                                                                                99
100                                                                                                                                                                               100
             XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
101          16e. Provider address                                                                                                                                                101
102                                                                                                                                                                               102
103                                                                                                                                                                               103
             XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
104          16f. City                                                                                                            16g. State 16h. ZIP code                        104
105                                                                                                                                                                               105
106                                                                                                                                                                               106
             XXXXXXXXXXXXXXXXXXXXXX                                                                                               XX         XXXXX-XXXX
107          16i. Provider (SSN)                           16j. Provider federal employer identification no. (FEIN)                                                               107
108                                                                                                                                                                               108
109                                                                                                                                                                               109
             999-99-9999                                   99-9999999
110          16k. Provider phone                           16l. Qualifying individual to provider relationship code                                                               110
111                                                                                                                                                                               111
112                                                                                                                                                                               112
             999-999-9999                                  XX
113                                                                                                                                                                               113
114            16m. Amount you paid to provider .................................................................  16m.                      , 999,999,999.00,            0 0     114
115                                                                                                                                                                               115
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                          150-101-197
129                       (Rev. 09-07-23, ver. 01)                                                                                           18892301020000                       129
130                                                                                                                                                                               130
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70                                                                                                                                                                                         70
71                                                                                                                                    Oregon Department of Revenue                         71
                       2023 Schedule OR-WFHDC-PR
72                                                                                                                                                                                         72
73                                                                                                                                                                                         73
74                     Page 3 of 4    • Use UPPERCASE letters.  • Use blue or black ink.  • Print actual size (100%).  • Don’t submit photocopies or use staples.                          74
75                                                                                                                                                                                         75
76           Section 2—Providers. Continued.                                                                                                                                               76
77           17a. Provider first name                          17b. Initial 17c. Provider last name                                                                                        77
78                                                                                                                                                                                         78
79                                                                                                                                                                                         79
             XXXXXXXXXXXXXXXX                                  X      XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
80           17d. Provider business name, if applicable                                                                                                                                    80
81                                                                                                                                                                                         81
82                                                                                                                                                                                         82
             XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
83           17e. Provider address                                                                                                                                                         83
84                                                                                                                                                                                         84
85                                                                                                                                                                                         85
             XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
86           17f. City                                                                                                     17g. State 17h. ZIP code                                        86
87                                                                                                                                                                                         87
88                                                                                                                                                                                         88
             XXXXXXXXXXXXXXXXXXXXXX                                                                                        XX         XXXXX-XXXX
89           17i. Provider SSN                             17j. Provider FEIN                                                                                                              89
90                                                                                                                                                                                         90
91                                                                                                                                                                                         91
             999-99-9999                                   99-9999999
92           17k. Provider phone                               17l. Qualifying individual to provider relationship code                                                                    92
93                                                                                                                                                                                         93
94                                                                                                                                                                                         94
             999-999-9999                                      XX
95                                                                                                                                                                                         95
96             17m. Amount you paid to provider. ................................................................  17m.               , 999,999,999.00,            0 0                     96
97                                                                                                                                                                                         97
98                                                                                                                                                                                         98
99                                                                                                                                                                                         99
100            18.  Total paid to providers. Add lines 16m and 17m ........................................18.                        , 999,999,999.00,            0 0                     100
101                                                                                                                                                                                        101
102          Section 3—Qualifying individuals. Complete all information for each qualifying individual who received care in 2022 that you                                                  102
103          paid for in 2023. List only the amounts paid in 2023 for services provided in 2022. If you have more than three qualifying individuals,                                       103
104          use an additional page.                                                                                                                                                       104
105          19a. First name                                   19b. Initial 19c. Last name                                                                                                 105
106                                                                                                                                                                                        106
107                                                                                                                                                                                        107
             XXXXXXXXXXXXXXXX                                  X      XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
108          19d. SSN                                      19e. Code* 19f. Date of birth (MM/DD/YYYY)                                 19g. Check if qualifying individual has a disability 108
109                                                                                                                                                                                        109
110          999-99-9999                                   XX         99/99/9999/                                /                    X                                                    110
111                                                                                                                                                                                        111
112                                                                                                                                                                                        112
113            19h. Total expenses paid for care ..................................................................   19h.            , 999,999,999.00,            0 0                     113
114                                                                                                                                                                                        114
115                                                                                                                                                                                        115
116           19i.  Portion of expensessomeone elsepaid for care on your behalf ................   19i.                               , 999,999,999.00,            0 0                     116
117                                                                                                                                                                                        117
118                                                                                                                                                                                        118
119           19j.  Portion of expensesyou paid for care ....................................................   19j.                  , 999,999,999.00,            0 0                     119
120                                                                                                                                                                                        120
121                                                                                                                                                                                        121
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123                                                                                                                                                                                        123
124                                                                                                                                                                                        124
125          *Qualifying individual to taxpayer relationship code—see instructions to determine the appropriate code.                               Continued on next page                 125
126                                                                                                                                                                                        126
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                       150-101-197
129                    (Rev. 09-07-23, ver. 01)                                                                                       18892301030000                                       129
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70                                                                                                                                                                              70
71                                                                                                                         Oregon Department of Revenue                         71
                         2023 Schedule OR-WFHDC-PR
72                                                                                                                                                                              72
73                                                                                                                                                                              73
74                       Page 4 of 4 • Use UPPERCASE letters.  • Use blue or black ink.  • Print actual size (100%).  • Don’t submit photocopies or use staples.                74
75           Section 3—Qualifying individuals. Continued.                                                                                                                       75
76           20a. First name                                       20b. Initial 20c. Last name                                                                                  76
77                                                                                                                                                                              77
78                                                                                                                                                                              78
             XXXXXXXXXXXXXXXX                                      X         XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
79           20d. SSN                                        20e. Code*      20f. Date of birth (MM/DD/YYYY)               20g. Check if qualifying individual has a disability 79
80                                                                                                                                                                              80
81           999-99-9999                                     XX              99/99/9999/       /                           X                                                    81
82                                                                                                                                                                              82
83                                                                                                                                                                              83
84             20h. Total expenses paid for care ..................................................................   20h. , 999,999,999.00,                     0 0            84
85                                                                                                                                                                              85
86                                                                                                                                                                              86
87            20i. Portion of expensessomeone else paid for care on your behalf ................   20i.                    , 999,999,999.00,                     0 0            87
88                                                                                                                                                                              88
89                                                                                                                                                                              89
90            20j.  Portion of expensesyou paid for care ....................................................   20j.       , 999,999,999.00,                     0 0            90
91                                                                                                                                                                              91
92           21a. First name                                       21b. Initial 21c. Last name                                                                                  92
93                                                                                                                                                                              93
94                                                                                                                                                                              94
             XXXXXXXXXXXXXXXX                                      X         XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
95           21d. SSN                                        21e. Code*      21f. Date of birth (MM/DD/YYYY)               21g. Check if qualifying individual has a disability 95
96                                                                                                                                                                              96
97           999-99-9999                                     XX              99/99/9999/       /                           X                                                    97
98                                                                                                                                                                              98
99                                                                                                                                                                              99
100            21h. Total expenses paid for care ..................................................................   21h. , 999,999,999.00,                     0 0            100
101                                                                                                                                                                             101
102                                                                                                                                                                             102
103           21i. Portion of expensessomeone else paid for care on your behalf ................   21i.                    , 999,999,999.00,                     0 0            103
104                                                                                                                                                                             104
105                                                                                                                                                                             105
106           21j.  Portion of expensesyou paid for care ....................................................   21j.       , 999,999,999.00,                     0 0            106
107                                                                                                                                                                             107
108                                                                                                                                                                             108
109                                                                                                                                                                             109
110           22.  Total expenses. Add lines 19h, 20h, and 21h. .........................................   22.            , 999,999,999.00,                     0 0            110
111                                                                                                                                                                             111
112                                                                                                                                                                             112
113           23.  Expenses   someone else         paid. Add lines 19i, 20i, and 21i. ...................   23.            , 999,999,999.00,                     0 0            113
114                                                                                                                                                                             114
115                                                                                                                                                                             115
116           24.  Total expenses    you paid. Add lines 19j, 20j, and 21j. .............................   24.            , 999,999,999.00,                     0 0            116
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                         150-101-197
129                      (Rev. 09-07-23, ver. 01)                                                                          18892301040000                                       129
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