New Mexico NEW MEXICO CAREGIVER'S STATEMENT

NEW MEXICO CAREGIVER'S STATEMENT
Form PIT-CG
PIT-CG
Rev. 04/29/2021

New Mexico Taxation and Revenue Department

Caregiver's Statement

Purpose of this worksheet: Use the Caregiver's Statement along with the PIT-Childcare, Child Day Care Credit Worksheet when claiming
the New Mexico Child Day Care Credit on the PIT-RC. Please print legibly using blue or black ink. Keep original forms for your records
and submit copies with your PIT-1 return. Important: An incomplete PIT-RC or missing PIT-CG will result in the denial of the credit.
First Name, Middle Initial, and Last Name

Social Security Number (SSN)

Instructions: The caregiver must complete the PIT-CG Sections I and Section II. Both the caregiver and taxpayer must complete the
Signature section. Each caregiver needs a separate PIT-CG. Note: Do not include any charges for childcare for periods of unemployment
or for childcare provided either before or after work (plus any necessary travel time) or for periods the taxpayer is attending school.
Section I: Qualifications for Individual Caregivers (Caregiver complete all fields)
Name (Business Name or First Name, Middle Initial, and Last Name)

NMBTIN or SSN

Mailing Address

City, State, and Zip Code

1.	 Were you, as a caregiver, age 18 or over at the time the care was performed?
2.	 Did you, as a caregiver, provide day care service for less than 24 hours daily?

Yes o

No

3.	 Were you a dependent of the above taxpayer for whom you provided childcare services?

Yes o

No

Yes o

No

o
o
o

Section II: Statement of Compensation Received by Caregiver (Caregiver, complete all applicable fields)

Tax Year

20____

Month

Child 1
Name:
SSN:
No. of
Days

Compensation
Amount Received Per
Month

Child 2

Child 3

Child 4

Name:

Name:

Name:

SSN:

SSN:

SSN:

No. of
Days

Compensation Amount
Received Per Month

No. of
Days

Compensation Amount
Received Per Month

No. of
Days

Compensation
Amount Received
Per Month

January
February
March
April
May
June
July
August
September
October
November
December
Total
Section III: If Unable To Have Caregiver Complete PIT-CG (Taxpayer, complete Section I,II, and III)
If you made all reasonable attempts to have the caregiver complete the PIT-CG schedule and you were unable to locate the caregiver or to obtain
the required information, complete Section I and Section II of this schedule based on previous billings or other records. Explain below why the
caregiver did not complete the statement.

Signature: Both Caregiver and Taxpayer Must Sign Below
I herby certify and declare that the information reported on this form and any attached supplement(s) are true and correct:
Caregiver- Print Name

Caregiver- Signature

Date

Caregiver Title

Caregiver- Email Address

Caregiver- Phone Number

Taxpayer- Print Name

Taxpayer Signature

Date