Free Daycare Year-End Tuition Statement (Printable, for Form 2441)

In January, parents ask their child care provider for a statement of what they paid last year. They need it to claim the child and dependent care credit on Form 2441, or to get paid back from a dependent care FSA. Form 2441 asks for the provider's name, address and taxpayer identification number (your SSN or EIN) and the amount paid, so the statement below has a line for each of those.

Fill in the boxes and the statement updates as you type. Nothing you type leaves your browser. Many providers leave the ID number out here and write it on the printed copy by hand.

Your details

Provider or daycare name

SSN or EIN (optional)

Address

This family

Parent name

Children

Tax year

Total paid in the year ($)

Care from

Care to

Child Care Payment Statement,

This statement confirms that paid a total of for the care of from to .

Provider name:
Address:
Taxpayer ID (SSN or EIN):

Date: ____________________

Provider signature

Print one per family. Change the parent, children and amount, then print again.

The full set of 13 home daycare forms adds an incident report, sign-in sheet, medication log and a parent handbook outline, for $9.

A statement for every family at once

The Home Daycare Bookkeeping Bundle keeps a payment log for each family through the year, so the year-end statement fills in its own total from what you logged. It also has a Time-Space calculator, an expense tracker and an attendance and meal log, for Google Sheets and Excel.

Home Daycare Bookkeeping Bundle, $19

Also for tax time, see home daycare tax deductions and IRS daycare meal rates 2026. This is a record-keeping aid, not tax advice.