Schedule                   North Dakota Office of State Tax Commissioner

ND-1FC                        Family Member Care Tax Credit
                                                                                                                                                                2018
                                                                                                                                                        Attach to Form ND-1
Name(s) shown on return                                                                                           Your social security number

•  If you paid qualified care expenses for more than one qualifying family member, complete a separate Schedule ND-1FC for each qualifying family 
   member.
•  See the instructions for definitions of “qualifying family member” and “qualified care expenses.”

        Qualifying family member criteria
   A.   Is the family member related to you by blood or marriage? .........................................................................                     ○ Yes ○ No
        If yes, enter your relationship to the family member ..................................... __________________________
   B.   Is the family member either (1) at least 65 years old or (2) disabled as defined by the
        Social Security Administration?  If disabled, attach a copy of a supporting letter—see instructions ....................                              ○   Yes ○ No
   C.   If the family member is not married, is the family member’s federal taxable income equal to or less 
       than $20,000?  If the family member is married, is the total federal taxable income of the family member and
       the family member’s spouse equal to or less than $35,000? ........................................................................                     ○   Yes ○ No
        •  If you answered “Yes” to all of the questions in Items A through C above, go to Item D.
        •  If you answered “No” to any question in Items A through C above, stop here;  you do not have a qualifying family member.
   D.   Name of qualifying family member ...........................................................................................   ► _________________________
   E.   Social security number of qualifying family member ....................................................................   ► _________________________

        Calculation of tax credit
   1.   Qualified care expenses paid by you during the tax year for the qualifying family member identified above
       (Attach a statement showing type and amount of expenses.  If payment is for services, also identify provider)                                          1 _________________
   2.   Of the expenses included on line 1, enter the amount deducted on federal return .....................................                                 2 _________________
   3.   Eligible qualified care expenses (Subtract line 2 from line 1.  If less than zero, enter -0-) ...........................  (FA)                       3 _________________
   4.   Your federal taxable income (from Form 1040, line 10)..............................................(FB) 4  _______________
   5.   Decimal amount (from applicable table below) (If Married Filing Separately, use Table 2 to find income range,
       then enter one-half of decimal amount for that range) .........................................................................  (FC)                  5       . ___ ___
         Table 1: Single/Head of household/Qualifying widow(er)     Table 2: Married filing joint
          If the amount Decimal        If the amount Decimal        If the amount     Decimal              If the amount                 Decimal
          on line 4 is: amount is:     on line 4 is: amount is:     on line 4 is:     amount is:           on line 4 is:                 amount is:
          Over    Not over             Over      Not over           Over Not over                          Over   Not over 
          $    0  $ 25,000    .30      $ 35,000  $ 37,000   .24     $    0  $ 35,000      .30              $ 45,000  $ 47,000                           .24
            25,000    27,000  .29        37,000    39,000   .23       35,000    37,000    .29                47,000    49,000                           .23
            27,000    29,000  .28        39,000    41,000   .22       37,000    39,000    .28                49,000    51,000                           .22
            29,000    31,000  .27        41,000    43,000   .21       39,000    41,000    .27                51,000    53,000                           .21
            31,000    33,000  .26        43,000   No limit  .20       41,000    43,000    .26                53,000   No limit                          .20
            33,000    35,000  .25                                     43,000    45,000    .25
   6.   Multiply line 3 by line 5 ....................................................................................................................  (FD)  6 _________________
   7.   Maximum credit allowed per qualifying family member.  Enter $2,000 if Single, Married Filing Jointly,
       Head of Household, or Qualifying Widow(er), or $1,000 if Married Filing Separately  .................................  (FE)                            7 ________________
   8.   Enter smaller of line 6 or line 7 .........................................................................................................  (FF)     8  _______________
   9.   Federal taxable income limit.  Enter $50,000 ifSingle, Head of Household,   orQualifying Widow(er),
        or $70,000 if Married Filing Jointly, or $35,000 if Married Filing Separately .................(FG)     9 _________________
 10.    Subtract line 9 from line 4 (If less than zero, enter -0-) ..............................................................  (FH) 10  _______________
 11.    Tentative family member care credit (Subtract line 10 from line 8) (If less than zero, enter -0-)
        See below for the amount you may enter on your return ..............................................................             (FI) 11  _______________

        •  If you are claiming this credit for only one qualifying family member, enter the amount from line 11
           of Schedule ND-1FC on Schedule ND-1TC, line 1.

        •  If you are claiming this credit for more than one qualifying family member, add the separately calculated credits from line 11 
           of all Schedule ND-1FC forms.  Your allowable credit is limited to the smaller of the sum of the separately calculated credits 
           or $4,000 ($2,000, if you are Married Filing Separately).  Enter your allowable credit on Schedule ND-1TC, line 1.

North Dakota Office of State Tax Commissioner
 2018 Schedule ND-1FC instructions

Eligibility for credit                      •  Provided to or for the benefit of (or        Qualified care expenses deducted for 
                                            needed by the taxpayer to care for) a           federal income tax purposes are not eligible 
If you paid qualified care expenses for a   qualifying family member;                       for the credit.
qualifying family member during the tax 
year, you may be able to take the family    •  Provided by an organization or individual 
member care income tax credit.  See         not related to the taxpayer or the              Qualifying family member
“Qualified care expenses” and “Qualifying   qualifying family member; and                   A qualifying family member is a person 
                                                                                            who:
family member” below.  If you qualify for   •  Not compensated for by insurance or a 
the credit, you must complete this schedule federal or state assistance program.            1.  Is related to you by blood or marriage.
and attach it to your return.
                                            Companionship services —Companionship           2.  Is either at least 65 years old or disabled 
You must attach a statement showing the     services means services that provide            as defined by the Social Security 
type and amount of the qualified care       fellowship, care and protection for a person    Administration. Attach a copy of a 
expenses you paid during the tax year.  In  who is unable to care for his or her own        letter from a physician, the ND Dept. 
the case where the expense is for services, needs because of advanced age or a physical     of Human Services, or other competent 
you also must identify the person or        or mental disability.  These services include   authority that attests the qualifying 
organization that performed the services.   household work directly related to the          family member meets SSA’s definition of 
                                            care of the aged or disabled person, such       a qualifying disability.
If you paid qualified care expenses         as meal preparation, bed making, washing        3.  Has federal taxable income equal to or 
for more than one qualifying family         clothes and other similar services.  These      less than:
member, you must complete a separate        services may also include household work 
Schedule ND-1FC for each qualifying         not directly related to the care of the aged or   a.  $20,000, if not married.
family member.                              disabled person if the time it takes to do this   b.  $35,000, if married. (Include both 
                                            work during any week does not exceed 20%            spouses’ incomes.)
Qualified care expenses                     of the total hours worked during that same 
Qualified care expenses means expenses      week.                                           The taxpayer and the qualifying family 
                                                                                            member may not be the same person.
for home health agency services,            Companionship services do not include 
companionship services (see below),         services which require, and are performed 
personal care attendant services,           by, trained personnel.  This includes a 
homemaker services, adult day care,         registered or practical nurse, or services to 
respite care, and any other expenses that   care for and protect infants and children who 
are deductible medical expenses under       are not physically or mentally disabled.
federal income tax law.  To qualify, the 
expense must be: