Form Schd-ND1-FC Family Member Care Credit

25 000 27 000 29 37 000 39 000 23 35 000 37 000 29 47 000 49 000 23 27 000 29 000 28 39 000 41 000 22 37 000 39 000 28 49 000 51 000 22 29 000 31 000 27 41 000 43 000 21 39 000 41 000 27 51 000 53 000 21 31 000 33 000 26 43 000 No limit 20 41 000 43 000 26 53 000 No limit 20 $ 0 $ 25 000 30 $ 35 000 $ 37 000 24 $ 0 $ 35 000 30 $ 45 000 $ 47 000 24 (Attach a statement showing type and amount of expenses If payment is for services also identify provider) 1 1 Quali ed care expenses paid by you during the tax year (for the qualifying family member identi ed above) 2 Of the expenses included on line 1 enter the amount deducted on federal return 2 2012 Schedule ND 1FC instructions 33 000 35 000 25 43 000 45 000 25 a $20 000 if not married A Is the family member related to you by blood or marriage? Yes No A qualifying family member is a person who: Attach to Form ND 1 b $35 000 if married (Include both spouses incomes ) B Is the family member either (1) at least 65 years old or (2) disabled as de ned by the Social Security Administration? If disabled attach a copy of a supporting letter see instructions Yes No C If the family member is not married is the family member s federal taxable income equal to or less than $20 000? If the family member is married is the total federal taxable income of the family member and the family member s spouse equal to or less than $35 000? Yes No Calculation of tax credit Companionship services Companionship services means services that provide fellowship care and protection for a person who is unable to care for his or her own needs because of advanced age or a physical or mental disability These services include household work directly related to the care of the aged or disabled person such as meal preparation bed making washing clothes and other similar services These services may also include household work not directly related to the care of the aged or disabled person if the time it takes to do this work during any week does not exceed 20% of the total hours worked during that same week Companionship services do not include services which require and are performed by trained personnel This includes a registered or practical nurse or services to care for and protect infants and children who are not physically or mentally disabled D Name of qualifying family member Decimal amount (from applicable table below) (If Married ling separately use Table 2 to nd income range then enter one half of decimal amount for that range) (FC) 5 E Social security number of qualifying family member Eligibility for credit Eligible quali ed care expenses (Subtract line 2 from line 1 If less than zero enter 0 ) (FA) 3 Enter smaller of line 6 or line 7 (FF) 8 Federal taxable income limit Enter $50 000 if Single or Head of household or Has federal taxable income equal to or less than: If the amount Decimal If the amount Decimal If the amount Decimal If the amount Decimal If yes enter your relationship to the family member If you answered NO to any question in Items A through C above stop here; you do not have a qualifying family member If you answered YES to all of the questions in Items A through C above go to Item D If you are claiming this credit for more than one qualifying family member add the separately calculated credits from line 11 of all Schedule ND 1FC forms Your allowable credit is limited to the smaller of the sum of the separately calculated credits or $4 000 ($2 000 if you are married ling separately) Enter your allowable credit on Schedule ND 1TC line 1 If you are claiming this credit for only one qualifying family member enter the amount from line 11 If you paid quali ed care expenses for a qualifying family member during the tax year you may be able to take the family member care income tax credit See Quali ed care expenses and Qualifying family member below If you qualify for the credit you must complete this schedule and attach it to your return If you paid quali ed care expenses for more than one qualifying family member complete a separate Schedule ND 1FC for each qualifying family member If you paid quali ed care expenses for more than one qualifying family member you must complete a separate Schedule ND 1FC for each qualifying family member Is either at least 65 years old or disabled as de ned by the Social Security Administration Attach a copy of a letter from a physician the ND Dept of Human Services or other competent authority that attests the qualifying family member meets SSA s de nition of a qualifying disability Is related to you by blood or marriage Married ling separately (FG) 9 Maximum credit allowed per qualifying family member Enter $2 000 if Single or Married ling jointly or Head of household or Qualifying widow(er) or $1 000 if Married ling separately (FE) 7 Multiply line 3 by line 5 (FD) 6 Name(s) shown on return ND 1FC Family member care income tax credit North Dakota Of ce of State Tax Commissioner Not compensated for by insurance or a federal or state assistance program of Schedule ND 1FC on Schedule ND 1TC line 1 OffOff OffOff on line 4 is: amount is: on line 4 is: amount is: on line 4 is: amount is: on line 4 is: amount is: Over Not over Over Not over Over Not over Over Not over Provided by an organization or individual not related to the taxpayer or the qualifying family member; and Provided to or for the bene t of (or needed by the taxpayer to care for) a qualifying family member; Quali ed care expenses Quali ed care expenses deducted for federal income tax purposes are not eligible for the credit Quali ed care expenses means expenses for home health agency services companionship services (see below) personal care attendant services homemaker services adult day care respite care and other expenses that are deductible medical expenses under federal income tax law To qualify the expense must be: Qualifying family member Qualifying family member criteria Qualifying widow(er) or $70 000 if Married ling jointly or $35 000 if Schedule North Dakota Of ce of State Tax Commissioner See the instructions on the other side of this schedule for de nitions of qualifying family member and quali ed care expenses Social security number Subtract line 9 from line 4 (If less than zero enter 0 ) (FH) 10 Table 1: Single/Head of household/Qualifying widow(er) Table 2: Married ling joint Tentative family member care credit (Subtract line 10 from line 8) (If less than zero enter 0 ) See below for the amount you may enter on your return (FI) 11 The taxpayer and the qualifying family member may not be the same person You must attach a statement showing the type and amount of the quali ed care expenses you paid during the tax year In the case where the expense is for services you also must identify the person or organization that performed the services Your federal taxable income (from line 43 of Form 1040 line 27 of Form 1040A or line 6 of Form 1040EZ) (FB) 4