Rev. 09/13/2016
PIT-CG               NEW MEXICO CAREGIVER'S STATEMENT
The caregiver must complete this PIT-CG and give it to the taxpayer to attach to the PIT-1 Return and Schedule PIT-RC. Each caregiver who 
provides daycare services for which a credit amount is claimed completes a separate PIT-CG. Failure to attach the required PIT-CG to the 
PIT-1 will cause the amount claimed for the child daycare credit to be disallowed. Attach the Child Day Care Credit Worksheet to the PIT-CG.
The caregiver must furnish the information on the number of days care was provided each month and the compensation received for 
each child for whom the credit is claimed. The caregiver must answer the three qualification questions; enter their name, address, phone  
number, and New Mexico CRS identification number; and sign this PIT-CG.  The name and social security number for each child receiving  
daycare services is required on this PIT-CG. The taxpayer must also sign.
Do not include any charges for childcare for periods of unemployment or for childcare provided either before or after work (plus any necessary 
travel time) or for periods the taxpayer is attending school.
Taxpayer's first name and initial (as it appears on Form PIT-1) Taxpayer's last name                        Taxpayer's  social security number

 PART I. QUALIFICATIONS FOR INDIVIDUAL CAREGIVERS
Caregiver's name                Caregiver's address                                               Caregiver's New Mexico CRS ID or SSN

 1.  Were you, as a caregiver, age 18 or over at the time the care was performed?                           YES                    NO
 2.  Did you, as a caregiver, provide daycare service for less than 24 hours daily?                         YES                    NO
 3.  Were you a dependent of the above taxpayer for whom you provided childcare services?                   YES                    NO

 PART II. STATEMENT OF COMPENSATION RECEIVED BY CAREGIVER
 TAX YEAR        CHILD 1 Name and SSN     CHILD 2 Name and SSN                  CHILD 3 Name and SSN        CHILD 4  Name and SSN
 20___
                        Compensation                            Compensation                  Compensation         Compensation 
     Month       No. of Amount Received   No. of                Amount Received No. of Amount Received      No. of Amount Received 
                 Days           Per Month Days                  Per Month       Days          Per Month     Days   Per Month
 JANUARY
 FEBRUARY
 MARCH
 APRIL
 MAY
 JUNE
 JULY
 AUGUST
 SEPTEMBER
 OCTOBER
 NOVEMBER
 DECEMBER
 TOTAL

Caregiver's signature _____________________________________          Caregiver's phone number __________________ __________

PART III. TAXPAYER: IF YOU COULD NOT OBTAIN A STATEMENT FROM THE CAREGIVER, COMPLETE THIS PART OF                                  THE FORM.
If you made all reasonable attempts to complete this PIT-CG schedule, and you are still unable to locate the caregiver or to obtain the 
required information, complete Parts I and II of this schedule based on previous billings or other records, provide the name and address 
of the caregiver, and explain below why the caregiver did not complete the statement.

                                                                Taxpayer's signature ___________________________________________