FAMILY MEMBER CARE TAX CREDIT
                               OFFICE OF STATE TAX COMMISSIONER 
                               SFN 28731 (12-2022)                                                                                              Schedule ND-1FC

                                                                                                                                                       2022
                                                                                                                                                Attach to Form ND-1
 Name(s) Shown On Return                                                                                   Your Social Security Number

  •  If you paid qualified care expenses for more than one qualifying family member, complete a separate Schedule ND-1FC for each qualifying    
     family member.
   • See the instructions for definitions of “qualifying family member” and “qualified care expenses.”

Qualifying family member criteria
  A.   Is the family member related to you by blood or marriage? ......................................................................                    Yes  No

       If yes, enter your relationship to the family member ...................................._________________________

  B.   Is the family member either (1) at least 65 years old or (2) disabled as defined by the                                                             Yes  No
       Social Security Administration? If disabled, attach a copy of a supporting letter—see instructions ..................  
  C.   If the family member is not married, is the family member’s federal taxable income on the 2022 Form 1040 or
       1040-SR, line 15, equal to or less than $20,000? If the family member is married, is the total federal taxable                                      Yes  No
       income of the family member and the family member’s spouse equal to or less than $35,000? .....................
       • If you answered “Yes” to all of the questions in Items A through C above, go to Item D.
       • If you answered “No” to any question in Items A through C above, stop here; you do not have a qualifying family member.
  D.   Name of qualifying family member .................................................................................................... ► __________________
  E.   Social security number of qualifying family member ............................................................................. ► __________________

       Calculation of tax credit
  1.   Qualified care expenses paid by you during the tax year for the qualifying family member identified above.
       Attach a statement showing type and amount of expenses. If payment is for services, also identify provider                                1  __________________
  2.   Of the expenses included on line 1, enter the amount, if any, deducted on federal return ............................                     2     __________________
  3.   Eligible qualified care expenses. Subtract line 2 from line 1. If less than zero, enter -0- .......................(FA) 3___________________
  4.   Your federal taxable income from 2022 Form 1040 or 1040-SR, line 15 .............................................                        (FB) 4 _________________
  5.   Decimal amount from applicable table below. If Married Filing Separately, use Table 2 to find
       income range, then enter one-half of decimal amount for that range.     ................................................(FC) 5                           . ___ ___
        Table 1: Single/Head of household/Qualifying widow(er)        Table 2: Married filing joint
         If the amount    Decimal      If the amount   Decimal        If the amount Decimal           If the amount                             Decimal
         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 
         $      0  $ 25,000    .30     $ 35,000  $ 37,000  .24        $       0  $ 35,000 .30         $ 45,000  $ 47,000                               .24
           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
           33,000    35,000    .25                                      43,000    45,000  .25
  6.   Multiply line 3 by line 5 ...............................................................................................................(FD) 6 ___________________
   7.  Maximum credit allowed per qualifying family member. Enter $2,000 if Single, Married Filing Jointly,
       Head of Household, or Qualifying Widow(er), or $1,000 if Married Filing Separately ............................. (FE) 7                        __________________
  8.   Enter smaller of line 6 or line 7 ....................................................................................................(FF) 8  _________________
  9.   Federal taxable income limit. Enter $50,000 if Single, Head of Household, or Qualifying Widow(er),
      or $70,000 if Married Filing Jointly, or $35,000 if Married Filing Separately ......................................(FG) 9                      ___________________
 10.   Subtract line 9 from line 4. If less than zero, enter -0- ..........................................................(FH) 10                    _________________
 11.   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 _________________

       • If you are claiming this credit for only one qualifying family member, enter the amount from line 11
         of Schedule ND-1FC on Schedule ND-1TC, line 1.

       • 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 (or $2,000 if Married Filing Separately). Enter your allowable credit on Schedule ND-1TC, 
         line 1.

 2022 Schedule ND-1FC
SFN 28731 (12-2022), Page 2

Eligibility for credit                    •  Provided to or for the benefit       Qualified care expenses 
If you paid qualified care expenses     of (or needed by the taxpayer             deducted for federal income tax 
for a qualifying family member during   to care for) a qualifying family          purposes are not eligible for the 
the tax year, you may be able to take   member;                                   credit.
the family member care income tax         •  Provided by an organization 
credit. See “Qualified care expenses”   or individual not related to the          Qualifying family member
and “Qualifying family member” below.   taxpayer or the qualifying family         A qualifying family member is a 
If you qualify for the credit, you must member; and                               person who:
complete this schedule and attach it to   •  Not compensated for by insurance     1.  Is related to you by blood or 
your return.                            or a federal or state assistance           marriage.
                                        program.
You must attach a statement                                                       2.  Is either at least 65 years old 
showing the type and amount of          Companionship services  —                  or disabled as defined by the 
the qualified care expenses you         Companionship services means               Social Security Administration. 
paid during the tax year. In the        services that provide fellowship, care     Attach a copy of a letter 
case where the expense is for           and protection for a person who is         from a physician, the ND 
services, you also must identify        unable to care for his or her own needs    Dept. of Human Services, or 
the person or organization that         because of advanced age or a physical      other competent authority 
performed the services.                 or mental disability. These services       that attests the qualifying 
                                        include household work directly related    family member meets SSA’s 
If you paid qualified care expenses     to the care of the aged or disabled        definition of a qualifying 
for more than one qualifying family     person, such as meal preparation,          disability.
member, you must complete a             bed making, washing clothes and           3.  Has federal taxable income equal 
separate Schedule ND-1FC for each       other similar services. These services     to or less than:
qualifying family member.               may also include household work not 
                                        directly related to the care of the aged   a. $20,000, if not married.
Qualified care expenses                 or disabled person if the time it takes    b. $35,000, if married. (Include 
Qualified care expenses means           to do this work during any week does       both spouses’ incomes.)
expenses for home health agency         not exceed 20% of the total hours 
services, companionship services        worked during that same week.             The taxpayer and the qualifying 
(see below), personal care attendant                                              family member may not be the 
services, homemaker services, adult     Companionship services do not include     same person.
day care, respite care, and any other   services which require, and are 
expenses that are deductible medical    performed by, trained personnel. This 
expenses under federal income tax law.  includes a registered or practical nurse, 
To qualify, the expense must be:        or services to care for and protect 
                                        infants and children who are not 
                                        physically or mentally disabled.