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

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 ______

Provider Signature ______Date ______