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5                                                                                                                                  Oregon Department of Revenue                     5
                        2022 Schedule OR-WFHDC-PR
6                       Working Family Household and Dependent Care Credit for Prior Year Expenses                                                                                  6
7                                                                                                                                                                                   7
8                       Page 1 of 4  • Use UPPERCASE letters.  • Use blue or black ink.  • Print actual size (100%).  • Don’t submit photocopies or use staples.                    8
9           Last name                                                                                                           Social Security number (SSN)                        9
10                                                                                                                                                                                  10
11                                                                                                                                                                                  11
            XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                                                                    999-99-9999
12                                                                                                                                                                                  12
13          Instructions: Use this worksheet only if you paid providers in early 2022 for services received toward the end of the year in 2021.                                     13
14          You will need information from your 2021 Oregon return and Schedule OR-WFHDC to complete this worksheet. If you didn’t claim                                            14
15          this credit for tax year 2021, you will need to complete federal Form 2441, Child and Dependent Care Expenses, for 2021 even if you                                     15
16          didn’t claim the federal credit. Keep this worksheet with your tax records.                                                                                             16
17                                                                                                                                                                                  17
18          Section 1—Credit for prior year expenses.                                                                                                                               18
19                                                                                                                                                                                  19
20            1.  Enter your 2021 qualified expenses paid in 2021 .....................................   1.                       ,                         999,999,999.00, 0 0    20
21                                                                                                                                                                                  21
22                                                                                                                                                                                  22
23            2.  Enter your 2021 qualified expenses paid in 2022 .....................................   2.                       ,                         999,999,999.00, 0 0    23
24                                                                                                                                                                                  24
25                                                                                                                                                                                  25
26            3.  Add lines 1 and 2 .......................................................................................   3.   ,                         999,999,999.00, 0 0    26
27                                                                                                                                                                                  27
28                                                                                                                                                                                  28
29            4.  Enter the amount from line 18 of your 2021 Schedule OR-WFHDC .........   4.                                      ,                         999,999,999.00, 0 0    29
30                                                                                                                                                                                  30
31            5.  Enter the smaller of your and your spouse’s 2021 earned income. If you                                                                                            31
32                claimed the WFHDC credit in 2021, this is the smaller of lines 20 and 21                                                                                          32
33                on your 2021 Schedule OR-WFHDC. If you  didn’t claim the credit in                                                                                                33
34                2021, fill out federal Form 2441 for 2021. Use the amounts listed on                                                                                              34
35                lines 4 and 5 (or lines 18 and 19 if lines 4 or 5 are blank). Don’t enter                                                                                         35
36                less than zero.............................................................................................   5. ,                         999,999,999.00, 0 0    36
37                                                                                                                                                                                  37
38                                                                                                                                                                                  38
39            6.  Enter the smallest amount from lines 3, 4, or 5 above..............................   6.                         ,                         999,999,999.00, 0 0    39
40                                                                                                                                                                                  40
41            7.  If you claimed the credit in 2021, enter the amount you claimed on                                                                                                41
42                line 22 of your 2021 Schedule   OR-WFHDC. If you didn’t claim the                                                                                                 42
43                credit in 2021, enter zero ...........................................................................   7.      ,                         999,999,999.00, 0 0    43
44                                                                                                                                                                                  44
45            8.  Line 6 minus line 7.  Enter the result. If zero or less, stop here. You can’t                                                                                     45
46                increase your 2022 credit based on prior year’s expenses.                                                                                                         46
47                If more than zero, continue to line 9 ............................................................8.             ,                         999,999,999.00, 0 0    47
48                                                                                                                                                                                  48
49            9.  Enter your 2021 federal adjusted gross income (2021 Form OR-40,                                                                                                   49
50                line 7; Form OR-40-N or Form OR-40-P, line 29F) ...................................   9.                         ,                         999,999,999.00, 0 0    50
51                                                                                                                                                                                  51
52           10.  Enter your 2021 Oregon adjusted gross income (2021 Form OR-40,                                                                                                    52
53                line 7; Form OR-40-N or Form OR-40-P, line 29S) ...................................10.                           ,                         999,999,999.00, 0 0    53
54                                                                                                                                                                                  54
55                                                                                                                                                                                  55
56           11.  Enter the greater of line 9 or line 10...........................................................11.             ,                         999,999,999.00, 0 0    56
57                                                                                                                                                                                  57
58                                                                                                                                                                                  58
59                                                                                                                                                           Continued on next page 59
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62                                                                                                                                                                                  62
                        150-101-197
63                      (Rev. 09-08-22, ver. 01)                                                                                   18892201010000                                   63
64                                                                                                                                                                                  64
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69                                                                                                                                                                                  69
70                                                                                                                                                                                  70
71                                                                                                                                             Oregon Department of Revenue         71
                          2022 Schedule OR-WFHDC-PR
72                                                                                                                                                                                  72
73                                                                                                                                                                                  73
74                        Page 2 of 4  • Use UPPERCASE letters.  • Use blue or black ink.  • Print actual size (100%).  • Don’t submit photocopies or use staples.                  74
75                                                                                                                                                                                  75
76            12.  Enter your decimal value from line 23 of your 2021 Schedule                                                                                                      76
77                  OR-WFHDC. If you didn’t claim  this credit in 2021, use the online                                                                                              77
78                  calculator for tax year 2021 and enter the decimal value .........................12.                                                          9.99 %           78
79                                                                                                                                                                                  79
80            13.  Multiply line 8 by line 12. If you filed a 2021 full-year resident return,                                                                                       80
81                  enter this amount on your   2022 Schedule OR- WFHDC, line 28. If you                                                                                            81
82                  filed a 2021 part- year or nonresident return, continue to line 14 ..............13.                                       , 999,999,999.00,            0 0     82
83                                                                                                                                                                                  83
84                                                                                                                                                                                  84
85            14.  Enter the decimal value from line 35 of your 2021 Form OR- 40- N or                                                                                              85
86                  Form OR-  40-  P ...........................................................................................14.                                999.9 %          86
87                                                                                                                                                                                  87
88            15.  Multiply line 13 by line 14 and enter this amount on your 2022                                                                                                   88
89                  Schedule OR-WFHDC, line 28 ..................................................................15.                           , 999,999,999.00,            0 0     89
90                                                                                                                                                                                  90
91                                                                                                                                                                                  91
92           Section 2—Providers. Complete all information for each provider you paid in 2022 for expenses incurred in 2021. Only list the                                          92
93           amounts you paid in 2022 that apply to services provided in 2021. If you have more than two providers, use an additional page.                                         93
94                                                                                                                                                                                  94
95           16a. Provider first name                      16b. Initial 16c. Provider last name                                                                                     95
96                                                                                                                                                                                  96
97                                                                                                                                                                                  97
             XXXXXXXXXXXXXXXX                              X       XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
98           16d. Provider business name, if applicable                                                                                                                             98
99                                                                                                                                                                                  99
100                                                                                                                                                                                 100
             XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
101          16e. Provider address                                                                                                                                                  101
102                                                                                                                                                                                 102
103                                                                                                                                                                                 103
             XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
104          16f. City                                                                                                              16g. State 16h. ZIP code                        104
105                                                                                                                                                                                 105
106                                                                                                                                                                                 106
             XXXXXXXXXXXXXXXXXXXXXX                                                                                                 XX         XXXXX-XXXX
107          16i. Provider (SSN)                           16j. Provider federal employer identification no. (FEIN)                                                                 107
108                                                                                                                                                                                 108
109                                                                                                                                                                                 109
             999-99-9999                                   99-9999999
110          16k. Provider phone                           16l. Qualifying individual to provider relationship code                                                                 110
111                                                                                                                                                                                 111
112                                                                                                                                                                                 112
             999-999-9999                                  XX
113                                                                                                                                                                                 113
114            16m. Amount you paid to provider .................................................................  16m.                        , 999,999,999.00,            0 0     114
115                                                                                                                                                                                 115
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                          150-101-197
129                       (Rev. 09-08-22, ver. 01)                                                                                             18892201020000                       129
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70                                                                                                                                                                                        70
71                                                                                                                                   Oregon Department of Revenue                         71
                       2022 Schedule OR-WFHDC-PR
72                                                                                                                                                                                        72
73                                                                                                                                                                                        73
74                     Page 3 of 4    • Use UPPERCASE letters.  • Use blue or black ink.  • Print actual size (100%).  • Don’t submit photocopies or use staples.                         74
75                                                                                                                                                                                        75
76           Section 2—Providers. Continued.                                                                                                                                              76
77           17a. Provider first name                          17b. Initial 17c. Provider last name                                                                                       77
78                                                                                                                                                                                        78
79                                                                                                                                                                                        79
             XXXXXXXXXXXXXXXX                                  X      XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
80           17d. Provider business name, if applicable                                                                                                                                   80
81                                                                                                                                                                                        81
82                                                                                                                                                                                        82
             XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
83           17e. Provider address                                                                                                                                                        83
84                                                                                                                                                                                        84
85                                                                                                                                                                                        85
             XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
86           17f. City                                                                                                    17g. State 17h. ZIP code                                        86
87                                                                                                                                                                                        87
88                                                                                                                                                                                        88
             XXXXXXXXXXXXXXXXXXXXXX                                                                                       XX         XXXXX-XXXX
89           17i. Provider SSN                             17j. Provider FEIN                                                                                                             89
90                                                                                                                                                                                        90
91                                                                                                                                                                                        91
             999-99-9999                                   99-9999999
92           17k. Provider phone                               17l. Qualifying individual to provider relationship code                                                                   92
93                                                                                                                                                                                        93
94                                                                                                                                                                                        94
             999-999-9999                                      XX
95                                                                                                                                                                                        95
96             17m. Amount you paid to provider. ................................................................  17m.              , 999,999,999.00,            0 0                     96
97                                                                                                                                                                                        97
98                                                                                                                                                                                        98
99                                                                                                                                                                                        99
100            18.  Total paid to providers. Add lines 16m and 17m ........................................18.                       , 999,999,999.00,            0 0                     100
101                                                                                                                                                                                       101
102          Section 3—Qualifying individuals. Complete all information for each qualifying individual who received care in 2021 that you                                                 102
103          paid for in 2022. List only the amounts paid in 2022 for services provided in 2021. If you have more than three qualifying individuals,                                      103
104          use an additional page.                                                                                                                                                      104
105          19a. First name                                   19b. Initial 19c. Last name                                                                                                105
106                                                                                                                                                                                       106
107                                                                                                                                                                                       107
             XXXXXXXXXXXXXXXX                                  X      XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
108          19d. SSN                                      19e. Code* 19f. Date of birth (MM/DD/YYYY)                                19g. Check if qualifying individual has a disability 108
109                                                                                                                                                                                       109
110          999-99-9999                                   XX         99/99/9999/                                /                   X                                                    110
111                                                                                                                                                                                       111
112                                                                                                                                                                                       112
113           19h. Total expenses paid for care ..................................................................   19h.            , 999,999,999.00,            0 0                     113
114                                                                                                                                                                                       114
115                                                                                                                                                                                       115
116           19i.  Portion of expensessomeone elsepaid for care on your behalf ................   19i.                              , 999,999,999.00,            0 0                     116
117                                                                                                                                                                                       117
118                                                                                                                                                                                       118
119           19j.  Portion of expensesyou paid for care ....................................................   19j.                 , 999,999,999.00,            0 0                     119
120                                                                                                                                                                                       120
121                                                                                                                                                                                       121
122                                                                                                                                                                                       122
123                                                                                                                                                                                       123
124                                                                                                                                                                                       124
125          *Qualifying individual to taxpayer relationship code—see instructions to determine the appropriate code.                              Continued on next page                 125
126                                                                                                                                                                                       126
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                       150-101-197
129                    (Rev. 09-08-22, ver. 01)                                                                                      18892201030000                                       129
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70                                                                                                                                                                             70
71                                                                                                                        Oregon Department of Revenue                         71
                         2022 Schedule OR-WFHDC-PR
72                                                                                                                                                                             72
73                                                                                                                                                                             73
74                       Page 4 of 4 • Use UPPERCASE letters.  • Use blue or black ink.  • Print actual size (100%).  • Don’t submit photocopies or use staples.               74
75           Section 3—Qualifying individuals. Continued.                                                                                                                      75
76           20a. First name                                       20b. Initial 20c. Last name                                                                                 76
77                                                                                                                                                                             77
78                                                                                                                                                                             78
             XXXXXXXXXXXXXXXX                                      X         XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
79           20d. SSN                                        20e. Code*      20f. Date of birth (MM/DD/YYYY)              20g. Check if qualifying individual has a disability 79
80                                                                                                                                                                             80
81           999-99-9999                                     XX              99/99/9999/       /                          X                                                    81
82                                                                                                                                                                             82
83                                                                                                                                                                             83
84            20h. Total expenses paid for care ..................................................................   20h. , 999,999,999.00,                      0 0           84
85                                                                                                                                                                             85
86                                                                                                                                                                             86
87            20i. Portion of expensessomeone else paid for care on your behalf ................   20i.                   , 999,999,999.00,                      0 0           87
88                                                                                                                                                                             88
89                                                                                                                                                                             89
90            20j.  Portion of expensesyou paid for care ....................................................   20j.      , 999,999,999.00,                      0 0           90
91                                                                                                                                                                             91
92           21a. First name                                       21b. Initial 21c. Last name                                                                                 92
93                                                                                                                                                                             93
94                                                                                                                                                                             94
             XXXXXXXXXXXXXXXX                                      X         XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
95           21d. SSN                                        21e. Code*      21f. Date of birth (MM/DD/YYYY)              21g. Check if qualifying individual has a disability 95
96                                                                                                                                                                             96
97           999-99-9999                                     XX              99/99/9999/       /                          X                                                    97
98                                                                                                                                                                             98
99                                                                                                                                                                             99
100           21h. Total expenses paid for care ..................................................................   21h. , 999,999,999.00,                      0 0           100
101                                                                                                                                                                            101
102                                                                                                                                                                            102
103           21i. Portion of expensessomeone else paid for care on your behalf ................   21i.                   , 999,999,999.00,                      0 0           103
104                                                                                                                                                                            104
105                                                                                                                                                                            105
106           21j.  Portion of expensesyou paid for care ....................................................   21j.      , 999,999,999.00,                      0 0           106
107                                                                                                                                                                            107
108                                                                                                                                                                            108
109                                                                                                                                                                            109
110           22.  Total expenses. Add lines 19h, 20h, and 21h. .........................................   22.           , 999,999,999.00,                      0 0           110
111                                                                                                                                                                            111
112                                                                                                                                                                            112
113           23.  Expenses   someone else         paid. Add lines 19i, 20i, and 21i. ...................   23.           , 999,999,999.00,                      0 0           113
114                                                                                                                                                                            114
115                                                                                                                                                                            115
116           24.  Total expenses    you paid. Add lines 19j, 20j, and 21j. .............................   24.           , 999,999,999.00,                      0 0           116
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                         150-101-197
129                      (Rev. 09-08-22, ver. 01)                                                                         18892201040000                                       129
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