Oregon Department of Revenue 2021 Schedule OR-WFHDC Oregon Working Family Household and Dependent Care Credit Page 1 of 5 • Use UPPERCASE letters. • Use blue or black ink. • Print actual size (100%). • Don’t submit photocopies or use staples. Space for 2-D barcode—do not write in box below Read instructions carefully before completing this form. You may be required to provide proof of care expenses you paid and other documentation to validate your credit. First name Initial Last name Social Security number (SSN) Attending school Disabled Spouse’s first name Initial Spouse’s last name Spouse’s SSN Attending school Disabled Section 1—Providers. Complete all information for each provider. 1a. Provider first name 1b. Initial 1c. Provider last name 1d. Provider business name 1e. Provider address 1f. City 1g. State 1h. ZIP code 1i. Provider SSN 1j. Provider individual taxpayer identification no. (ITIN) 1k. Provider federal employer identification no. (FEIN) 1l. Provider phone 1m. Qualifying individual to provider relationship code 0 0 , , 1n. Amount you paid to provider.................................................................... 1n. Continued on next page 150-101-195 (Rev. 08-28-21, ver. 01) 18382101010000 Clear form

2021 Schedule OR-WFHDC Oregon Department of Revenue Page 2 of 5 • Use UPPERCASE letters. • Use blue or black ink. • Print actual size (100%). • Don’t submit photocopies or use staples. Section 1—Providers. Continued. Complete all information for each provider. 2a. Provider first name 2b. Initial 2c. Provider last name 2d. Provider business name 2e. Provider address 2f. City 2g. State 2h. ZIP code 2i. Provider SSN 2j. Provider individual taxpayer identification no. (ITIN) 2k. Provider federal employer identification no. (FEIN) 2l. Provider phone 2m. Qualifying individual to provider relationship code , , 2n. Amount you paid to provider.................................................................... 2n. 0 0 3a. Provider first name 3b. Initial 3c. Provider last name 3d. Provider business name 3e. Provider address 3f. City 3g. State 3h. ZIP code 3i. Provider SSN 3j. Provider individual taxpayer identification no. (ITIN) 3k. Provider federal employer identification no. (FEIN) , , 0 0 3m. Qualifying individual to provider relationship code 3l. Provider phone 3n. Amount you paid to provider.................................................................... 3n. 4. Total the amounts you paid to the providers on lines 1n, 2n, and 3n here........................................................................................ 4. , , 0 0 Continued on next page 150-101-195 (Rev. 08-28-21, ver. 01) 18382101020000

2021 Schedule OR-WFHDC Oregon Department of Revenue Page 3 of 5 • Use UPPERCASE letters. • Use blue or black ink. • Print actual size (100%). • Don’t submit photocopies or use staples. Section 2—Qualifying individuals. List your qualifying individuals in order from youngest to oldest. Complete all information for each qualifying individual. 5a. First name 5b. Initial 5c. Last name 5d. SSN 5e. Code* * 5f. Date of birth (MM/DD/YYYY) / / 5g. Disabled 5h. Total expenses paid for care.................................................................... 5h. 5i. Portion of expenses someone else paid on your behalf ................................ 5i. 5j. Portion of expenses you paid for care...................................................... 5j. , , 0 0 , , 0 0 , , 0 0 6a. First name 6b. Initial 6c. Last name 6d. SSN 6e. Code* * 6f. Date of birth (MM/DD/YYYY) / / 6g. Disabled 6h. Total expenses paid for care.................................................................... 6h. 6i. Portion of expenses someone else paid on your behalf ................................ 6i. 6j. Portion of expenses you paid for care...................................................... 6j. , , 0 0 , , 0 0 , , 0 0 7a. First name 7b. Initial 7c. Last name 7d. SSN 7e. Code* * 7f. Date of birth (MM/DD/YYYY) / / 7h. Total expenses paid for care.................................................................... 7h. 7i. Portion of expenses someone else paid on your behalf ................................ 7i. 7j. Portion of expenses you paid for care...................................................... 7j. *Qualifying individual to taxpayer relationship code—see instructions to determine the appropriate code. 7g. Disabled , , , , 0 0 0 0 , , 0 0 Continued on next page 150-101-195 (Rev. 08-28-21, ver. 01) 18382101030000

2021 Schedule OR-WFHDC Oregon Department of Revenue Page 4 of 5 • Use UPPERCASE letters. • Use blue or black ink. • Print actual size (100%). • Don’t submit photocopies or use staples. Section 2—Qualifying individuals. Continued. 8. Total expenses. Add lines 5h, 6h, and 7h ................................................. 8. 9. Total expenses someone else paid. Add lines 5i, 6i, and 7i ..................... 9. 10. Total expenses you paid. Add lines 5j, 6j, and 7j .................................... 10. , , 0 0 , , 0 0 , , 0 0 Section 3—Household size calculation 11. Enter the number of regular exemptions you claimed on your 2021 Oregon return. Don’t include any extra exemptions for the severely disabled or a child with qualifying disability..................................................................... 11. 12. Enter the number of exemptions you didn’t claim on your 2021 Oregon return for one of the following reasons: ...... 12. • You released a child’s exemption to the child’s other parent. • The gross income of a qualifying individual with a disability was $4,300 or more. • The disabled qualifying individual filed a joint return with someone else. • You (or your spouse, if filing jointly) can be claimed as a dependent on someone else’s return. • You and your spouse filed a joint federal return and separate Oregon returns because you ended the year with a different residency status (enter 1 for your spouse). Note: Don’t count an exemption more than once. 13. Add lines 11 and 12 ........................................................................................................................................................ 13. 14. Enter the number of exemptions you claimed on your 2021 Oregon return for people who: ....................................... 14. • Didn’t live with you more than half of 2021. • Were released to you by the child’s other parent. • Aren’t related by blood, marriage, or adoption and who aren’t qualifying individuals. Note: Don’t count an exemption more than once. 15. Household size. Line 13 minus line 14 ........................................................................................................................... 15. Continued on next page 150-101-195 (Rev. 08-28-21, ver. 01) 18382101040000

2021 Schedule OR-WFHDC Oregon Department of Revenue Page 5 of 5 • Use UPPERCASE letters. • Use blue or black ink. • Print actual size (100%). • Don’t submit photocopies or use staples. Section 4—Computation of credit 16. If you’re claiming one qualifying individual, enter $12,000. If you’re claiming two or more qualifying individuals, enter $24,000.................... 16. 17. Enter the amount from federal Form 2441, line 28 (see instructions) ..... 17. 18. Line 16 minus line 17 ............................................................................... 18. 19. Enter the amount from line 10 ................................................................. 19. 20. Enter your earned income from federal Form 2441, line 4 that is taxable to Oregon (see instructions) ....................................................... 20. 21. If your filing status is married filing jointly, enter your spouse’s earned income from federal Form 2441, line 5 that is taxable to Oregon (see instructions). Otherwise, enter the amount from line 20 above.............. 21. 22. Enter the smallest amount from lines 18, 19, 20, or 21........................... 22. 23. Enter the decimal value from the online calculator (see instructions) .... 23. 24. Line 22 multiplied by line 23.................................................................... 24. 25. If you’re filing Form OR-40, enter the amount from line 24. If you’re filing Form OR-40-N or Form OR-40-P, multiply line 24 by your Oregon percentage (Form OR-40-N or Form OR-40-P, line 35) .............. 25. 26. If you paid 2020 expenses in 2021, complete Worksheet OR-WFHDC-PR and enter the amount from line 13 or line 15. Otherwise, enter 0............. 26. 27. Line 25 plus line 26. Enter the total here and on Schedule OR-ASC, Section F, or Schedule OR-ASC-NP, Section H, using code 895. .........................................................................This is your total credit. 27. , , 0 0 , , 0 0 , , 0 0 , , 0 0 , , 0 0 , , 0 0 , , 0 0 % 0 0 , , 0 0 , , 0 0 , , 0 0 , , —You must include this schedule with your Oregon income tax return when claiming this credit— 150-101-195 (Rev. 08-28-21, ver. 01) 18382101050000