3 Add the amounts in Column (C) of line 2. Do not enter more than $3,000 for one qualifying person, or $6,000 for two or more persons. If you completed Part III, enter the amount from line 35 . . . . . . . . . . . . . . . . . . . . . . . 3 4 Enter your earned income (see Federal Form 2441 instructions). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 5 If married, filing jointly, enter your spouse’s earned income. If your spouse was a student or was disabled, see instructions; all others, enter the amount from line 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 6 Enter the smallest of line 3, 4, or 5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 7 Enter federal AGI from Nebraska Form 1040N, line 5. If the amount is over $29,000, do not file this form, you are not eligible for the refundable child care tax credit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 8 Enter the federal decimal amount shown below that applies to the dollar amount on line 7. If line 7 is: If line 7 is: But Federal decimal But Federal decimal Over not over amount is Over not over amount is $ 0 – 15,000 .35 $21,000 – 23,000 .31 15,000 – 17,000 .34 23,000 – 25,000 .30 17,000 – 19,000 .33 25,000 – 27,000 .29 19,000 – 21,000 .32 27,000 – 29,000 .28 8 9 Enter the state decimal amount below that applies to the dollar amount on line 7. If line 7 is: If line 7 is: But Federal decimal But Federal decimal Over not over amount is Over not over amount is $0 or less – 22,000 1.00 $25,000 – 26,000 .60 22,000 – 23,000 .90 26,000 – 27,000 .50 23,000 – 24,000 .80 27,000 – 28,000 .40 24,000 – 25,000 .70 28,000 – 29,000 .30 9 10 Multiply line 6 by the decimal amount on line 8 and enter the result. If you paid 2021 expenses in 2022, see instructions on Federal Form 2441................................................................................................... 10 11 Multiply line 10 by the decimal amount on line 9. Residents enter result here and on line 32, Form 1040N.. . . . . . . . . . 11 12 Partial-year residents multiply line 11 by the ratio from line 4, Schedule III: Enter this

result here and on line 32, Form 1040N. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 13 Part III, dependent care benefits, begins on the next page. Nebraska Child and Dependent Care Expenses Name on Form 1040N Your Social Security Number • File Form 2441N ONLY if your adjusted gross income is $29,000 or less, and you are claiming the Nebraska refundable child and dependent care credit. • Complete the reverse side of this form if you received dependent care benefits. • Attach this form to Form 1040N. 2022 FORM 2441N BEFORE YOU BEGIN – Please see Federal Form 2441 instructions for definitions of the following terms: • Dependent Care Benefits • Qualifying Persons • Qualified Expenses Part I — Persons or Organizations Who Provide the Care • You must complete this part. (Paper filers, please attach a schedule if you need more space.) (A) (B) (C)

Care Address Identifying Number

Provider’s Name (Number, Street, Apt. No., City, State, and Zip Code) (SSN or EIN) Did you receive dependent care benefits? No Complete only Part II below. Yes Complete Part III on the back first, and then complete Part II. 1 Part II — Credit for Child and Dependent Care Expenses

(B) (C) Qualified Expenses You

Qualifying Person’s Incurred and Paid in 2022 for the

Social Security Number Person Listed in Column (A) 2 Information about your qualifying persons. (Paper filers, please attach a schedule if you have more than three qualifying persons.) 8-618-2022 . (D) Amount Paid (See Federal Form 2441 instructions) . (A) Qualifying Person’s Name First Last .

PRINT FORM RESET FORM

Part III — Dependent Care Benefits Dependent Care Benefits Name as Shown on Form 1040N Your Social Security Number 2022 FORM 2441N 14 Enter the total amount of dependent care benefits you received in 2022. Amounts you received as an employee should be shown in box 10 of your Federal Form W-2, but do not include amounts reported as wages in box 1 of Form W-2. If you were self-employed or a partner in a partnership, include amounts you received under a dependent care assistance program from your sole proprietorship or partnership. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 15 Enter the amount, if any, you carried over from 2020 or 2021 and used in 2022. See instructions on Federal Form 2441.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 16 If you forfeited or carried over to 2023 any of the amounts reported on line 14 or 15, enter the amount (see instructions). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 17 Subtract line 16 from total of line 14 and line 15. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 18 Enter the total amount of qualified expenses incurred in 2022 for the care of the qualifying persons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 19 Enter the smaller of line 17 or 18. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 20 Enter your earned income (see instructions). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 21 Enter the amount shown below that applies to you: • If married, filing jointly, enter your spouse’s earned income (if your spouse was a student or was disabled, see instructions); • If married, filing separately, see instructions for the amount to enter; or • All others, enter the amount from line 20 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 22 Enter the smallest of line 19, 20, or 21. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 23 Enter $5,000 (or enter $2,500 if married, filing separately, and you were required to enter your spouse’s earned income on line 21). If you entered an amount on line 15, add it to the $5,000 or $2,500 amount you enter on line 23. However, don't enter more than the maximum amount allowed under your dependent care plan. If your dependent care plan uses a non-calendar plan year, see federal instructions. . . 23 24 Enter the amount from line 14 or 15 that you received from your sole proprietorship or partnership. If you did not receive any such amounts, enter -0-. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 25 Subtract line 24 from line 17 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 26 Deductible benefits. Enter the smallest of line 22, 23, or 24. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 27 Enter the smaller of line 22 or 23 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 28 Enter the amount from line 26 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 29 Excluded benefits. Subtract line 28 from line 27. If zero or less, enter -0- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 30 Taxable benefits. Subtract line 29 from line 25. If zero or less, enter -0-. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 31 Enter $3,000 (or enter $6,000 if two or more qualifying persons) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 32 Add lines 26 and 29 and enter result here. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 33 Subtract line 32 from line 31. If zero or less, stop. You cannot take the credit.

Exception: If you paid 2021 expenses in 2022, see instructions on Federal Form 2441 . . . . . . . . . . . . . . . . . . 33 34 Complete line 2 on the front of this form. Do not include in Column (C) any benefits shown on line 32 above. Then, add the amounts in Column (C) and enter the total here . . . . . . . . . . . . . . . . . . . . . . . . . . 34 35 Enter the smaller of line 33 or 34. Also, enter this amount on line 3 on the front of this form and complete lines 4-12 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 To claim the child and dependent care credit, complete lines 31-35 below.

Instructions Nebraska generally follows federal definitions. For additional information, see the instructions for Federal Form 2441. Who May File. You may file Form 2441N to take the credit or the exclusion if all five of the following apply.

1. Your filing status is single, head of household, qualifying widow(er) with dependent child, or married, filing jointly. If your filing status is married, filing separately, see “Married Persons, Filing Separately” below.

2. The care was provided so you (and your spouse, if filing jointly) could work or look for work. However, if you did not find a job and have no earned income for the year, you cannot take the credit or the exclusion. If you or your spouse were a full-time student or disabled, see the instructions for lines 4 and 5.

3. The care must be for one or more qualifying persons.

4. The person who provided the care was not your spouse, the parent of your qualifying child, or a person whom you can claim as a dependent. If your child provided the care, he or she must have been age 19 or older by the end of 2022, and he or she cannot be your dependent.

5. You report the required information about the care provider on line 1, and if taking the credit, the information about the qualifying person on line 2.

6. Your federal AGI shown on your 1040N, line 5, is $29,000 or less. Married Persons, Filing Separately. Generally, married persons must file a married, filing jointly return to claim the credit. If your filing status is married, filing separately and all of the following apply, you are considered unmarried for purposes of claiming the credit or exclusion on Form 2441N.

• You lived apart from your spouse during the last 6 months of 2022.

• Your home was the qualifying person's main home for more than half of 2022.

• You paid more than half of the cost of keeping up that home for 2022. If you meet all the requirements to be treated as unmarried and meet items 2 through 5 under “Who May File,” you may take the credit or the exclusion. If you do not meet all the requirements to be treated as unmarried, you cannot take the credit; however, you may take the exclusion if you also meet items 2 through 5 under “Who May File.” Line Instructions Line 1. Complete columns (A) through (D) for each person or organization that provided the care. You can use any of the following sources to get this information:

• Federal Form W-10, Dependent Care Provider's Identification and Certification;

• A copy of the provider’s Social Security card or driver’s license that includes his or her Social Security number (SSN);

• A recently printed letterhead or printed invoice that shows the provider’s name, address, and Taxpayer ID Number (TIN); and

• A copy of the statement provided by your employer if you were covered by your employer’s dependent care plan and your employer furnished the care (either at your workplace or by hiring a care provider). If you do not give correct or complete information, your credit or exclusion will be disallowed. If you have more than three care providers, attach a statement to your return with the required information for each provider. Be sure to put your name and SSN on the statement. Also, enter “See Attached” under line 1(A). Columns (A) and (B). Enter the care provider's name and address. Column (C). If the care provider is an individual, enter his or her SSN. Otherwise, enter the provider's employer ID number (EIN). If the provider is a tax-exempt organization, enter “Tax-Exempt” in column (C). Column (D). Enter the total amount you actually paid to the care provider in 2022 and any amounts your employer paid to a third party on your behalf. It does not matter when the expenses were incurred. Do not reduce this amount by any reimbursement you received. Line 2. Complete columns (A) through (C) for each qualifying person. If you have more than three qualifying persons, attach a statement to your return with the required information. Be sure to put your name and SSN on the statement. In column (C) , enter the qualified expenses you incurred and paid in 2022 for the person listed in column (A). The amount entered in line 2 cannot exceed the amount actually paid to providers in line 1. Prepaid expenses are treated as paid in the year the care is provided. Line 3. Add the amounts in line 2, column (C). Do not enter more than $3,000 for one qualifying person, or $6,000 for two or more qualifying persons. If you completed Part III, enter the amount from line 35. Line 4. Enter your earned income as defined in the instructions for Federal Form 2441. If you are filing a married, filing jointly return, calculate the earned income of you and your spouse separately and enter your spouse’s earned income on line 5. See Note if you were a student or disabled.

Line 5. Enter your spouse’s earned income as defined in the instructions for Federal Form 2441. See Note if your spouse was a student or disabled. Note: If, in the same month, both you and your spouse were either full-time students or disabled, only one of you can be treated as having earned income in that month. If you or your spouse was a full-time student or disabled, calculate that person’s earned income on a monthly basis. For purposes of this calculation:

• A person would be considered a full-time student if he or she was enrolled as a full-time student at a school for some part of each of five calendar months during 2022. The months do not need to be consecutive. A school does not include an on-the-job training course, a correspondence school, or a school offering courses only through the Internet.

• A person would be considered disabled if he or she was not physically or mentally capable of self-care. For each month (or part of a month) that you or your spouse was a full-time student or disabled, that person is considered to have worked and earned income. That person’s earned income for each month is considered to be at least $250 ($500 if more than one qualifying person was cared for in 2022). If you or your spouse also worked during that month, use the higher of $250 (or $500) or that person's actual earned income for that month. For any month that you or your spouse were not a full-time student or disabled, use that person’s actual earned income if that person worked during the month. Line 6. Enter the smallest of lines 3, 4, or 5. Line 7. Enter the amount from line 5, Form 1040N. If the amount is more than $29,000, you are not eligible for the refundable child care tax credit. Do not complete this form, instead, see the nonrefundable tax credit instructions for line 23, Form 1040N, and use Federal Form 2441. Line 10. Multiply the amount on line 6 by the decimal amount on line 8 enter the result. If you had qualified expenses for 2021 that you did not pay until 2022, you may be able to increase the amount of credit you can take in 2022. Use the Worksheet A in Federal Publication 503, Child and Dependent Care Expenses, to determine if you can claim prior year expenses. If you can take a credit for prior year expenses (CPYE), add the additional amount of credit to the calculated line 10 amount, and write “CPYE” on the dotted line next to line 10. Also, attach a copy of the federal worksheet to your return. Taxpayers who e-file and claim a credit for prior year expenses on Form 2441N should include this documentation as a binary attachment. Line 11. Multiply line 10 by the decimal amount on line 9. Nebraska residents enter this result on line 11, Form 2441N, and on line 32, Form 1040N. Line 12. Partial-year residents multiply line 11 by the ratio on line 4, Nebraska Schedule III, Form 1040N. Enter the result here and on line 32, Form 1040N. Line 14. Enter the total amount of dependent care benefits you received in 2022. Amounts you received as an employee are shown in box 10 of your Federal Form W-2. If you were self-employed or a partner in a partnership, include amounts you received under a dependent care assistance program from your sole proprietorship or partnership. Line 15. If you had an employer-provided dependent care plan, your employer may have permitted you to carry forward any unused amount from 2021 to use during a grace period in 2022. Enter on line 15 the amount you carried forward and used in 2022 during the grace period. Line 16. If you had an employer-provided dependent care plan, enter the total of the following amounts included on line 14:

• Any amount you forfeited (if you did not receive it because you did not incur the expense). Do not include amounts you expect to receive at a future date; and

• Any amount you did not receive but are permitted by your employer to carry forward and use in the following year during a grace period. Example. Under your employer’s dependent care plan, you chose to have your employer set aside $5,000 to cover your 2022 dependent care expenses. The $5,000 is shown on your Form W-2, in box 10. In 2022, you incurred and were reimbursed for $4,950 of qualified expenses. Enter $5,000 on line 14, and $50, the amount forfeited, on line 16. Also, enter $50 on line 16 if, instead of forfeiting the amount, your employer permitted you to carry the $50 forward to use during the grace period in 2023. Line 18. Enter the total of all qualified expenses incurred in 2022 for the care of your qualifying persons. It does not matter when the expenses were paid. Example. You received $2,000 in cash under your employer’s dependent care plan for this tax year. The $2,000 is shown on your Form W-2 in box 10. Only $900 of qualified expenses were incurred in this tax year for the care of your 5-year-old dependent child. Enter $2,000 on line 14 and $900 on line 18. Line 20. Enter your earned income as defined in the federal instructions for Federal Form 2441. If you are filing a

married, filing jointly return, calculate the earned income of you and your spouse separately and enter your spouse’s earned income on line 5. See Note if you were a student or disabled. Line 21. Enter your spouse’s earned income as defined in the federal instructions for Federal Form 2441. See Note if your spouse was a student or disabled. Note: If, in the same month, both you and your spouse were either full-time students or disabled, only one of you can be treated as having earned income in that month. If you or your spouse was a full-time student or disabled, calculate that person’s earned income on a monthly basis. For purposes of this calculation:

• A person would be considered a full-time student if he or she was enrolled as a full-time student at a school for some part of each of five calendar months during 2022. The months do not need to be consecutive. A school does not include an on-the-job training course, a correspondence school, or a school offering courses only through the Internet.

• A person would be considered disabled if he or she was not physically or mentally capable of self-care.