Annual Child Care Income Report (W-10)



Annual Child Care Income Report (W-10)

Provided here is a report of the annual amount paid to me for Child Care services provided for:

______________________________________________________________

First Last DOB

______________________________________________________________

First Last DOB

My records show that a total of $__________ for the year _________ was paid to me by one or both of the following:

_____________________________________________

First Last

_____________________________________________

First Last

The above total yearly amount was paid to:

Provider Name

Business Name

Address

Address

SSN or EIN

You will need to sign and date this form and return one copy to me and keep one for your records. It is important to me that the amount we both report to the IRS match.

If you find that your records indicate a different amount, please notify me of the discrepancy

Parent Signature _____________________________ Date ____________

Parent Signature _____________________________ Date ____________

Provider Signature ____________________________ Date ____________

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