2200810055 2200810055 PA-40 DC (EX) MOD 08-22 (FI) PA Department of Revenue 2200810055 OFFICIAL USE ONLY 1. CARE PROVIDER'S NAME FULL ADDRESS OF PROVIDER SSN/FEIN ID TYPE Provide all information for each person/organization. If more than five, submit additional schedules as needed. SSN Name (if filing jointly, use name shown first on the PA-40) Social Security Number (shown first) Spouse’s Name Spouse’s Social Security Number In order to claim child and dependent care expenses, you must also claim the expenses on your Federal 1040 return. Include with the PA Schedule DC a completed copy of your federal Form 2441 and 1040 Schedule 3. PERSONS/ORGANIZATIONS WHO PROVIDED CARE SECTION I PA SCHEDULE DC Child and Dependent Care Enhancement Tax Credit 2022 AMOUNT PAID FEIN SSN FEIN SSN FEIN SSN FEIN SSN FEIN Provide all information about your qualifying person(s). If you have more than five qualifying persons, submit additional schedules as needed. QUALIFYING PERSON(S) TO CLAIM FOR CHILD AND DEPENDENT CARE EXPENSES SECTION II 1. QUALIFYING PERSON'S NAME FIRST NAME LAST NAME DOB (MM/DD/YYYY) SSN/ITIN RELATIONSHIP QUALIFIED EXPENSES (See instructions) INCOME AND CALCULATION OF CREDIT SECTION III 1. Enter the total number of qualifying persons from Section II from all Schedules DC. 1. 2. Enter the amount as shown on Line 9a of your federal Form 2441. 2. 3. Multiply Line 2 above by 30% (0.30). Enter on your PA-40, Line 23. 3. ID TYPE SSN ITIN SSN ITIN SSN ITIN SSN ITIN SSN ITIN START § IMPORTANT: FILL IN FORM MUST BE DOWNLOADED ONTO YOUR COMPUTER PRIOR TO COMPLETING PRINT NEXT PAGE TOP OF PAGE Reset Entire Form

PA-40 DC 1 www.revenue.pa.gov 2022 Instructions for PA-40 Schedule DC Child and Dependent Care Enhancement Tax Credit

Beginning tax year 2022, Pennsylvania residents who receive a credit under section 21 of the Internal Revenue Code of 1986 may claim a tax credit against their Pennsylvania tax liability. In order to claim the expenses on the PA Schedule DC, the taxpayer must also have claimed the expenses on their Federal 1040 return.

PURPOSE OF SCHEDULE The purpose of the PA-40 Schedule DC, Pennsylvania Child and Dependent Care Enhancement Tax Credit is to claim a credit for child and dependent care expenses paid. IMPORTANT: A completed copy of the federal Form 2441 and the 1040 Schedule 3 must be included with the filing of the PA-40 return. Failure to include these forms will result in the credit being removed or deducted from Line 23 of the PA-40.

IDENTIFICATION INFORMATION Provide the name and Social Security number of the indi­ vidual shown first on the PA-40. If married, provide the name and Social Security number of the spouse, regardless of fil­ ing status.

NAME OF CARE PROVIDER Provide the name for each care provider (up to 5). Enter the full address for each care provider (up to 5), listing the street address on the top line and the city, state, and zip code on the bottom line. SOCIAL SECURITY NUMBER OR FEIN Enter the Social Security number or federal employer iden­ tification number for each care provider listed, if available. ID TYPE Fill in the appropriate oval to indicate if the ID provided is a SSN (Social Security number) or a FEIN (federal employer identification number). AMOUNT PAID Provide the amount paid to each care provider.

Provide all information about your qualifying person(s). NAME OF QUALIFYING INDIVIDUAL(S) Enter the first and last name of each qualifying person (up to 5). DATE OF BIRTH Provide the date of birth for each qualifying person in the format of month/day/year (MM/DD/YYYY). SOCIAL SECURITY NUMBER OR ITIN Enter the Social Security number or individual taxpayer iden­ tification number for each qualifying person. If the child was born and died in 2022 and didn't have a SSN, enter "Died". ID TYPE Fill in the appropriate oval to indicate if the ID provided is a SSN (Social Security number) or a ITIN (individual taxpayer identification number). If the qualifying person only has an ATIN (Adoption Taxpayer Identification number), fill in the oval for SSN. RELATIONSHIP Provide the taxpayer’s relationship to each qualifying person listed. QUALIFIED EXPENSES Enter the amount of qualified expenses for each qualifying person per the federal Form 2441, Part II, Line 2(d).

INCOME AND CALCULATION OF CREDIT

Enter the total number of qualifying persons from Section II from all Schedules DC.

Enter the amount as shown on Line 9a of the taxpayer’s fed­ eral Form 2441.

Multiply Line 2 above by 30% (0.30). Enter the amount on Line 23 of the PA-40. IMPORTANT: If you have more than 5 care providers, or more than 5 qualifying persons, you must submit ad­ ditional schedules as needed. GENERAL INFORMATION WHAT’S NEW LINE INSTRUCTIONS SECTION I SECTION II SECTION III LINE 1 LINE 2 LINE 3 FORM INSTRUCTIONS PA-40 DC IN 08-22 PRINT RETURN TO FORM