AR2441 1 see 2021

ARKANSAS INDIVIDUAL INCOME TAX CHILD AND DEPENDENT CARE EXPENSES

Primary's legal name Primary's social security number

You cannot claim a credit for child and dependent care expenses if your filing status 5 (married filing separately on different returns) unless you meet the requirements listed in the instructions under "Married Filing Separately on Different Returns." If you meet these requirements, check this box. []

Part | Persons or Organizations Who Provided the Care — You must complete this part. ar (If you have more than two care providers, see the instructions.)

1 (a) Care provider's (b) Address (c) Identifying number (d) Amount paid name (number, street, apt. no., city, state, and ZIP code) (SSN or EIN) (see instructions) Did you receive -—— No ——» Complete only Part II below.

dependent care benefits?

Yes ——» Complete Part Ill on the back next.

laaig Credit for Child and Dependent Care Expenses

2 Information about your qualifying person(s). If you have more than two qualifying persons, see the instructions. (a) Qualifying legal name (b) Qualifying person's social _ (c) Qualified expenses you security number incurred and paid in 2021 for the First Last person listed in column (a) 3 Add the amounts in column (c) of line 2. Don't enter more than $3,000 for one qualifying person or $6,000 for 3 two or more persons. If you completed Part Ill, enter the amount from line 30... 2... ...2..2.00.. 4 Enter your earned income. See instructions ... 2... 2... ee 4 5 If married filing status 2 or 4, enter your spouse's earned income ( if you or your spouse was a student or was disabled, see the instructions); all others, enter the amount from line4...............2...... 5 6 Enter the smallest ofline3,4,0r5 2... 0. ee 6 7 Enter the amount from Form 1040, 1040-SR, or 1040-NR, line 11........ | 7 | 8 Enter on line 8 the decimal amount shown below that applies to the amount on line 7. If line 7 is: If line 7 is: But not Decimal But not Decimal Over over amount is Over over amount is $0 — 15,000 35 $29,000 — 31,000 .27 15,000 — 17,000 34 31,000 — 33,000 26 17,000 — 19,000 33 33,000 — 35,000 25 8 X. 19,000 — 21,000 32 35,000 — 37,000 24 21,000 — 23,000 31 37,000 — 39,000 23 23,000 — 25,000 30 39,000 — 41,000 22 25,000 — 27,000 29 41,000 — 43,000 21 27,000 — 29,000 28 43,000 — No limit .20 9 Multiply line 6 by the decimal amountonline8.. 2... 2. 9 10 Multiply line 9 by .20. Enter this amount on line 35 and/or line 43 of AR1000F/AR1000NR............ 10

AR2441 Pg1 (R 10/4/2021)

AR2441 th

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P2

Part III Dependent Care Benefits

11

12

13 14 15

16 17 18

19 20

21

22 23

24

25

Enter the total amount of dependent care benefits you received in 2021. Amounts you received as an employee should be shown in box 10 of your Form(s) W-2. Don't include amounts reported as wages in box 1 of Form(s) W-2. If you were self-employed or a partner, include amounts you received under a dependent care assitance program from your sole propriertorship or partnership.

Enter the amount, if any, you carried over from 2020 and used in 2021 during the grace period. See instructions .. 2... ee

Enter the amount, if any, you forfeited or carried forward to 2022. See instructions ..............0..

Combine lines 11 through 13. See instructions .. 2... 2... ee

11

12

13

14

Enter the total amount of qualified expenses incurred in 2021 for the care of the qualifying person(s) .... 2.2... ..0.20 0.202.200.2020 000. 15

Enter the smaller ofline 140r15 2... 2... ....2...2.022005. 16

Enter your earned income. See instructions ................... 17

Enter the amount shown below that applies to you.

* If married filing status 2 or 4, enter your spouse's earned income (if you or your spouse was a student or was disabled, see 18

the instructions for line 5). * If married filing status 5, see instructions.

* All others, enter the amount from line 17.

Enter the smallest of line 16,17,or18..................000. 19

Enter $5,000 ($2,500 if married filing status 5 and you were required to enter your spouse's earned income online 18)... ..............200- 20

ls any amount on line 11 from your sole proprietorship or partnership? 0 No. Enter -0-

OO Yes. Enterthe amounthere... 2.2... 0020-02000 00000 eee ce

Subtract line 21 fromline14 2.2... ee ee 22

21

Deductible benefits. Enter the smallest of line 19, 20, 21. Also, include this amount on the appropriate line(s) of your return. See instructions 2... 2...

Excluded benefits. If you checked "No" on line 21, enter the smaller of line 19 or 20. Otherwise, subtract line 23 from the smaller of line 19 or line 20. If zeroorless,enter-O-.................0.

Taxable benefits. Subtract line 24 from line 22. If zero or less, enter -0-. If more that zero, see instructions . . . .

23

24

25

To claim the child and dependent care credit, complete lines 26 through 30 below.

26

27

28

29

30

Enter $3,000 ($6,000 if two or more qualifying persons)... 2... 2... ee

Add lines 23 and 24 2... 2 ee

Subtract line 27 from line 26. If zero or less, stop. You can't take the credit. Exception. If you paid 2020 expenses in2021. 2.0.0.0 20 00000000202 ee

Complete line 2 on the front of this form. Don't include in column (c) any benefits shown on line 27 above. Then, add the amounts in column (c) andenterthe totalhere .. 2.2... .....20..0 2000.20.00 .2000-

Enter the smaller of line 28 or 29. Also, enter this amount on line 3 on the front of this form and complete lines 4 through 10 2... ee

26

27

28

29

30

AR2441 Pg2 (R 12/13/2021)