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5                                                                                                                               Oregon Department of Revenue               5
                       2023 Schedule OR-WFHDC
6                      Oregon Working Family Household and Dependent Care Credit                                                                                           6
7                                                                                                                                                                          7
8                      Page 1 of 5  • Use UPPERCASE letters.  • Use blue or black ink.  • Print actual size (100%).  • Don’t submit photocopies or use staples.            8
9                                                                                                                Space for 2-D barcode—do not write in box below           9
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19                                                                                                                                                                         19
20          Read instructions carefully before completing this form.                                                                                                       20
21          You may be required to provide proof of care expenses you paid                                                                                                 21
22          and other documentation to validate your credit.                                                                                                               22
23                                                                                                                                                                         23
24          First name                                Initial     Last name                                                                                                24
25                                                                                                                                                                         25
26                                                                                                                                                                         26
            XXXXXXXXXXXXXXXX                          X           XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
27          Social Security number (SSN)                                                                                                                                   27
28                                                                                                                                                                         28
29          999-99-9999                               X       Attending school X                                 Disabled                                                  29
30          Spouse first name                         Initial     Spouse last name                                                                                         30
31                                                                                                                                                                         31
32                                                                                                                                                                         32
            XXXXXXXXXXXXXXXX                          X           XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
33          Spouse SSN                                                                                                                                                     33
34                                                                                                                                                                         34
35          999-99-9999                               X       Attending school X                                 Disabled                                                  35
36                                                                                                                                                                         36
37          Section 1—Providers. Complete all information for each provider.                                                                                               37
38          1a. Provider first name                   1b. Initial 1c. Provider last name                                                                                   38
39                                                                                                                                                                         39
40                                                                                                                                                                         40
            XXXXXXXXXXXXXXXX                          X           XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
41          1d. Provider business name, if applicable                                                                                                                      41
42                                                                                                                                                                         42
43                                                                                                                                                                         43
            XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
44          1e. Provider address                                                                                                                                           44
45                                                                                                                                                                         45
46                                                                                                                                                                         46
            XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
47          1f. City                                                                                                  1g. State 1h. ZIP code                               47
48                                                                                                                                                                         48
49                                                                                                                                                                         49
            XXXXXXXXXXXXXXXXXXXXXX                                                                                    XX        XXXXX-XXXX
50          1i. Provider SSN                          1j. Provider federal employer identification no. (FEIN)                                                              50
51                                                                                                                                                                         51
52                                                                                                                                                                         52
            999-99-9999                               99-9999999
53          1k. Provider phone                        1l. Qualifying individual to provider relationship code                                                              53
54                                                                                                                                                                         54
55                                                                                                                                                                         55
            999-999-9999                              XX
56                                                                                                                                                                         56
57          1m.  Amount you paid to the provider ................................................................ 1m.           , 999,999,999.00,                0 0       57
58                                                                                                                                                                         58
59                                                                                                                                           Continued on next page        59
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62                                                                                                                                                                         62
                       150-101-195
63                     (Rev. 08-14-23, ver. 01)                                                                                 18382301010000                             63
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70                                                                                                                                                                                        70
71                      2023 Schedule OR-WFHDC                                                                                                        Oregon Department of Revenue        71
72                                                                                                                                                                                        72
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74                      Page 2 of 5  • Use UPPERCASE letters.  • Use blue or black ink.  • Print actual size (100%).  • Don’t submit photocopies or use staples.                          74
75                                                                                                                                                                                        75
76           Section 1—Providers. Continued. Complete all information for each provider.                                                                                                  76
77           2a. Provider first name                   2b. Initial 2c. Provider last name                                                                                                 77
78                                                                                                                                                                                        78
79                                                                                                                                                                                        79
             XXXXXXXXXXXXXXXX                          X           XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
80           2d. Provider business name, if applicable                                                                                                                                    80
81                                                                                                                                                                                        81
82                                                                                                                                                                                        82
             XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
83           2e. Provider address                                                                                                                                                         83
84                                                                                                                                                                                        84
85                                                                                                                                                                                        85
             XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
86           2f. City                                                                                                                       2g. State 2h. ZIP code                        86
87                                                                                                                                                                                        87
88                                                                                                                                                                                        88
             XXXXXXXXXXXXXXXXXXXXXX                                                                                                         XX        XXXXX-XXXX
89           2i. Provider SSN                          2j. Provider federal employer identification no. (FEIN)                                                                            89
90                                                                                                                                                                                        90
91                                                                                                                                                                                        91
             999-99-9999                               99-9999999
92           2k. Provider phone                        2l. Qualifying individual to provider relationship code                                                                            92
93                                                                                                                                                                                        93
94                                                                                                                                                                                        94
             999-999-9999                              XX
95                                                                                                                                                                                        95
96           2m.  Amount you paid to provider .....................................................................  2m.                              , 999,999,999.00,            0 0    96
97                                                                                                                                                                                        97
98           3a. Provider first name                   3b. Initial 3c. Provider last name                                                                                                 98
99                                                                                                                                                                                        99
100                                                                                                                                                                                       100
             XXXXXXXXXXXXXXXX                          X           XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
101          3d. Provider business name, if applicable                                                                                                                                    101
102                                                                                                                                                                                       102
103                                                                                                                                                                                       103
             XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
104          3e. Provider address                                                                                                                                                         104
105                                                                                                                                                                                       105
106                                                                                                                                                                                       106
             XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
107          3f. City                                                                                                                       3g. State 3h. ZIP code                        107
108                                                                                                                                                                                       108
109                                                                                                                                                                                       109
             XXXXXXXXXXXXXXXXXXXXXX                                                                                                         XX        XXXXX-XXXX
110          3i. Provider SSN                          3j. Provider federal employer identification no. (FEIN)                                                                            110
111                                                                                                                                                                                       111
112                                                                                                                                                                                       112
             999-99-9999                               99-9999999
113          3k. Provider phone                        3l. Qualifying individual to provider relationship code                                                                            113
114                                                                                                                                                                                       114
115                                                                                                                                                                                       115
             999-999-9999                              XX
116                                                                                                                                                                                       116
117          3m.  Amount you paid to provider .....................................................................  3m.                              , 999,999,999.00,            0 0    117
118                                                                                                                                                                                       118
119                                                                                                                                                                                       119
120            4. Total the amounts you paid to the providers on                                                                                                                          120
121               lines 1m, 2m, and 3m here         .................................................................................... 4.           , 999,999,999.00,            0 0    121
122                                                                                                                                                                                       122
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                        150-101-195
129                     (Rev. 08-14-23, ver. 01)                                                                                                      18382301020000                      129
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71                       2023 Schedule OR-WFHDC                                                                              Oregon Department of Revenue            71
72                                                                                                                                                                   72
73                                                                                                                                                                   73
74                       Page 3 of 5 • Use UPPERCASE letters.  • Use blue or black ink.  • Print actual size (100%).  • Don’t submit photocopies or use staples.     74
75           Section 2—Qualifying individuals.List your qualifying individuals in order from youngest to oldest. Complete all                                        75
76           information for each qualifying individual.                                                                                                             76
77           5a. First name                                  5b. Initial 5c. Last name                                                                               77
78                                                                                                                                                                   78
79                                                                                                                                                                   79
             XXXXXXXXXXXXXXXX                                X           XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
80           5d. SSN                                      5e. Code*      5f. Date of birth (MM/DD/YYYY)                                                              80
81                                                                                                                                                                   81
82           999-99-9999                                  XX             99/99/9999/   /                                     X 5g. Disabled                          82
83                                                                                                                                                                   83
84                                                                                                                                                                   84
85            5h.  Total expenses paid for care ....................................................................   5h.   , 999,999,999.00,                   0 0 85
86                                                                                                                                                                   86
87                                                                                                                                                                   87
88             5i.  Portion of expensessomeone else paid for care on your behalf ..................   5i.                    , 999,999,999.00,                   0 0 88
89                                                                                                                                                                   89
90                                                                                                                                                                   90
91             5j.  Portion of expenses you paid for care ......................................................   5j.       , 999,999,999.00,                   0 0 91
92                                                                                                                                                                   92
93           6a. First name                                  6b. Initial 6c. Last name                                                                               93
94                                                                                                                                                                   94
95                                                                                                                                                                   95
             XXXXXXXXXXXXXXXX                                X           XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
96           6d. SSN                                      6e. Code*      6f. Date of birth (MM/DD/YYYY)                                                              96
97                                                                                                                                                                   97
98           999-99-9999                                  XX             99/99/9999/   /                                     X 6g. Disabled                          98
99                                                                                                                                                                   99
100                                                                                                                                                                  100
101           6h.  Total expenses paid for care ....................................................................   6h.   , 999,999,999.00,                   0 0 101
102                                                                                                                                                                  102
103                                                                                                                                                                  103
104            6i.  Portion of expensessomeone else paid for care on your behalf ..................   6i.                    , 999,999,999.00,                   0 0 104
105                                                                                                                                                                  105
106                                                                                                                                                                  106
107            6j.  Portion of expenses you paid for care ......................................................   6j.       , 999,999,999.00,                   0 0 107
108                                                                                                                                                                  108
109          7a. First name                                  7b. Initial 7c. Last name                                                                               109
110                                                                                                                                                                  110
111                                                                                                                                                                  111
             XXXXXXXXXXXXXXXX                                X           XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
112          7d. SSN                                      7e. Code*      7f. Date of birth (MM/DD/YYYY)                                                              112
113                                                                                                                                                                  113
114          999-99-9999                                  XX             99/99/9999/   /                                     X 7g. Disabled                          114
115                                                                                                                                                                  115
116                                                                                                                                                                  116
117             7h.  Total expenses paid for care ....................................................................   7h. , 999,999,999.00,                   0 0 117
118                                                                                                                                                                  118
119                                                                                                                                                                  119
120            7i.  Portion of expensessomeone else paid for care on your behalf ..................   7i.                    , 999,999,999.00,                   0 0 120
121                                                                                                                                                                  121
122                                                                                                                                                                  122
123            7j.  Portion of expenses you paid for care ......................................................   7j.       , 999,999,999.00,                   0 0 123
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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                         150-101-195
129                      (Rev. 08-14-23, ver. 01)                                                                            18382301030000                          129
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71                       2023 Schedule OR-WFHDC                                                                    Oregon Department of Revenue                                                         71
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74                       Page 4 of 5 • 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—Qualifying individuals. Continued.                                                                                                                                               76
77                                                                                                                                                                                                      77
78             8.  Total expenses. Add lines 5h, 6h, and 7h .................................................   8. , 999,999,999.00,                                                                0 0 78
79                                                                                                                                                                                                      79
80                                                                                                                                                                                                      80
81             9.  Total expenses someone else paid. Add lines 5i, 6i, and 7i .....................   9.           , 999,999,999.00,                                                                0 0 81
82                                                                                                                                                                                                      82
83                                                                                                                                                                                                      83
84            10.  Total expenses you paid. Add lines 5j, 6j, and 7j ....................................   10.    , 999,999,999.00,                                                                0 0 84
85                                                                                                                                                                                                      85
86                                                                                                                                                                                                      86
87           Section 3—Household size calculation                                                                                                                                                       87
88                                                                                                                                                                                                      88
89            11.  Enter the number of regular exemptions you claimed on your 2023 Oregon return. Don’t include any extra                                                                               89
90                 exemptions for the severely disabled or a child with qualifying disability. .................................................................... 11.                             99  90
91                                                                                                                                                                                                      91
92                                                                                                                                                                                                      92
93            12.  Enter the number of exemptions you didn’t claim on your 2023 Oregon return for one of the following reasons: ...... 12.                                                          99  93
94                 • You released a child’s exemption to the child’s other parent.                                                                                                                      94
95                 • The gross income of a qualifying individual with a disability was $4,700 or more.                                                                                                  95
96                 • The disabled qualifying individual filed a joint return with someone else.                                                                                                         96
97                 • You (or your spouse, if filing jointly) can be claimed as a dependent on someone else’s return.                                                                                    97
98               • You and your spouse filed a joint federal return and separate Oregon returns because you ended the year with a                                                                       98
99                 different residency status (enter 1 for your spouse).                                                                                                                                99
100                Note: Don’t count an exemption more than once.                                                                                                                                       100
101                                                                                                                                                                                                     101
102           13.  Add lines 11 and 12 ........................................................................................................................................................ 13. 99  102
103                                                                                                                                                                                                     103
104                                                                                                                                                                                                     104
105           14.  Enter the number of exemptions you claimed on your 2023 Oregon return for people who: ....................................... 14.                                                99  105
106                • Didn’t live with you more than half of 2023.                                                                                                                                       106
107                • Were released to you by the child’s other parent.                                                                                                                                  107
108                • Aren’t related by blood, marriage, or adoption and who aren’t qualifying individuals.                                                                                              108
109                Note: Don’t count an exemption more than once.                                                                                                                                       109
110                                                                                                                                                                                                     110
111           15.  Household size. Line 13 minus line 14 ........................................................................................................................... 15.            99  111
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125                                                                                                                  Continued on next page                                                             125
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                         150-101-195
129                      (Rev. 08-14-23, ver. 01)                                                                  18382301040000                                                                       129
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71                      2023 Schedule OR-WFHDC                                                                                 Oregon Department of Revenue            71
72                                                                                                                                                                     72
73                                                                                                                                                                     73
74                      Page 5 of 5   • Use UPPERCASE letters.  • Use blue or black ink.  • Print actual size (100%).  • Don’t submit photocopies or use staples.      74
75                                                                                                                                                                     75
76           Section 4—Computation of credit                                                                                                                           76
77                                                                                                                                                                     77
78            16.  If you’re claiming one qualifying individual, enter $12,000. If you’re                                                                              78
79                 claiming two or more qualifying individuals, enter $24,000....................   16.                        , 999,999,999.00,                  0 0  79
80                                                                                                                                                                     80
81                                                                                                                                                                     81
82            17.  Enter the amount from federal Form 2441, line 28 (see instructions) .....   17.                             , 999,999,999.00,                  0 0  82
83                                                                                                                                                                     83
84                                                                                                                                                                     84
85            18.  Line 16 minus line 17 ...............................................................................   18. , 999,999,999.00,                  0 0  85
86                                                                                                                                                                     86
87                                                                                                                                                                     87
88            19.  Enter the amount from line 10 .................................................................   19.       , 999,999,999.00,                  0 0  88
89                                                                                                                                                                     89
90            20.  Enter your earned income from federal Form 2441, line 4 that is                                                                                     90
91                 taxable to Oregon (students see instructions) ........................................   20.                , 999,999,999.00,                  0 0  91
92                                                                                                                                                                     92
93            21.  If your filing status is married filing jointly, enter your spouse’s earned                                                                         93
94                 income from federal Form 2441, line 5 that is taxable to Oregon (students                                                                           94
95                 see instructions). Otherwise, enter the amount from line 20 above .........21.                              , 999,999,999.00,                  0 0  95
96                                                                                                                                                                     96
97                                                                                                                                                                     97
98            22.  Enter the smallest amount from lines 18, 19, 20, or 21..........................   22.                      , 999,999,999.00,                  0 0  98
99                                                                                                                                                                     99
100                                                                                                                                                                    100
101           23.  Enter the decimal value from the online calculator (see instructions) ....   23.                                                               9.99 101
102                                                                                                                                                                    102
103                                                                                                                                                                    103
104           24.  Line 22 multiplied by line 23 ....................................................................   24.    , 999,999,999.00,                  0 0  104
105                                                                                                                                                                    105
106           25.  If you (or your spouse, if your filing status is married filing jointly) were a                                                                     106
107                student, complete Schedule OR-WFHDC-ST and enter the amount from                                                                                    107
108                line 34. Otherwise, enter 0. ......................................................................   25.   , 999,999,999.00,                  0 0  108
109                                                                                                                                                                    109
110                                                                                                                                                                    110
111           26.  Enter the larger of line 24 or line 25 .........................................................   26.      , 999,999,999.00,                  0 0  111
112                                                                                                                                                                    112
113           27.  If you’re filing Form OR-40, enter the amount from line 26. If you’re                                                                               113
114                filing Form OR-40-N or Form OR-40-P, multiply line 26 by your                                                                                       114
115                Oregon percentage (Form OR-40-N or Form OR-40-P, line 35) ..............27.                                 , 999,999,999.00,                  0 0  115
116                                                                                                                                                                    116
117           28.  If you paid 2022 expenses in 2023, complete Schedule OR-WFHDC-PR                                                                                    117
118                and enter the amount from line 13 or line 15. Otherwise, enter 0 .............28.                           , 999,999,999.00,                  0 0  118
119                                                                                                                                                                    119
120           29.  Line 27 plus line 28. Enter the total here and on Schedule OR-ASC,                                                                                  120
121                Section F, or Schedule OR-ASC-NP, Section H, using code 895.                                                                                        121
122                 .........................................................................This is your total credit. 29.    , 999,999,999.00,                  0 0  122
123                                                                                                                                                                    123
124                                                                                                                                                                    124
125                           —You must include this schedule with your Oregon income tax return when claiming this credit—                                            125
126                                                                                                                                                                    126
127                                                                                                                                                                    127
128                                                                                                                                                                    128
                        150-101-195
129                     (Rev. 08-14-23, ver. 01)                                                                               18382301050000                          129
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