Form 8839 Qualified Adoption Expenses

Form

8839

Department of the Treasury
Internal Revenue Service (99)

Qualified Adoption Expenses
▶

OMB No. 1545-0074

2012

▶ Attach to Form 1040 or 1040NR.
For information about Form 8839 and its separate instructions, see www.irs.gov/form8839.

Your social security number

Name(s) shown on return

Part I

Attachment
Sequence No. 38

Information About Your Eligible Child or Children—You must complete this part. See instructions for
details, including what to do if you need more space.
Check if child was—

(a)
Child’s name

1
First

(b)
Child’s year
of birth
Last

(c)
(d)
born before
a child
1995 and with special
disabled
needs

(f)
Child’s
identifying number

(e)
a
foreign
child

(g)
Check if
adoption
became final in
2012 or earlier

Child
1
Child
2
Child
3

Caution. If the child was a foreign child, see Special rules in the instructions for line 1, column (e) before you complete Part II or
Part III. If you received employer-provided adoption benefits, complete Part III on the back next.

Part II

Adoption Credit
Child 1

2
3

Maximum adoption credit per
child . . . . . . . .
Did you file Form 8839 for a
prior year for the same child?
No. Enter -0-.
Yes. See instructions for
the amount to enter.
Subtract line 3 from line 2 .
Qualified adoption expenses
(see instructions) . . . .

}

4
5

6
7
8

9
10
11
12

2

$12,650

Child 2

00

$12,650

Child 3

00

$12,650

00

3
4
5

Caution.
Your
qualified
adoption expenses may not be
equal to the adoption expenses
you paid in 2012.
Enter the smaller of line 4 or line 5
6
Enter modified adjusted gross income (see instructions) . . . . .
Is line 7 more than $189,710?
No. Skip lines 8 and 9, and enter -0- on line 10.
Yes. Subtract $189,710 from line 7 . . . . . . . . . .
Divide line 8 by $40,000. Enter the result as a decimal (rounded
Do not enter more than 1.000 . . . . . . . . . . . . .
Multiply each amount on line 6
by line 9 . . . . . . .
10
Subtract line 10 from line 6 .
11

.

7

.
8
to at least three places).
. . . . . . . . .

Add the amounts on line 11, then see the instructions for the amount of Adoption Credit to
enter here and on Form 1040, line 53, or Form 1040NR, line 50. Check box c on that line and
enter "8839" in the space next to box c . . . . . . . . . . . . . . . . . . .

For Paperwork Reduction Act Notice, see your tax return instructions.

Cat. No. 22843L

9

×

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12
Form 8839 (2012)

Page 2

Form 8839 (2012)

Part III

Employer-Provided Adoption Benefits
Child 1

13

Maximum exclusion per child

14

Did you receive employerprovided adoption benefits for a
prior year for the same child?
No. Enter -0-.
Yes. See instructions for
the amount to enter.
Subtract line 14 from line 13

}

15
16

$12,650

13

Child 2

00

$12,650

Employer-provided adoption
benefits you received in 2012.
This amount should be shown
in box 12 of your 2012 Form(s)
W-2 with code T . . . .

Enter the smaller of line 15 or
line 16. But if the child was a
child with special needs and the
adoption became final in 2012,
enter the amount from line 15
18
Enter modified adjusted gross income (from
the worksheet in the instructions) . . . .
19
Is line 19 more than $189,710?
No. Skip lines 20 and 21, and enter -0on line 22.
20
Yes. Subtract $189,710 from line 19
Divide line 20 by $40,000. Enter the result as a decimal (rounded to
at least three places). Do not enter more than 1.000 . . . . .
Multiply each amount on line 18
by line 21 . . . . . . .
22
Excluded benefits. Subtract
line 22 from line 18 . . . .
23

22
23

00

16

18

21

$12,650

15

Add the amounts on line 16 .

20

00

14

17

19

Child 3

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×

21

24

Add the amounts on line 23 .

25

Taxable benefits. Is line 24 more than line 17?
No. Subtract line 24 from line 17. Also, include this amount, if more than zero, on
line 7 of Form 1040 or line 8 of Form 1040NR. On the dotted line next to line
7 of Form 1040 or line 8 of Form 1040NR, enter “AB.”
Yes. Subtract line 17 from line 24. Enter the result as a negative number. Reduce
the total you would enter on line 7 of Form 1040 or line 8 of Form 1040NR by
the amount on Form 8839, line 25. Enter the result on line 7 of Form 1040 or
line 8 of Form 1040NR. Enter “SNE” on the dotted line next to the entry line.

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17

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24

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25

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You may be able to claim the adoption credit in Part II on the front of this form if any of the following apply.

TIP

• You paid adoption expenses in 2011, those expenses were not fully reimbursed by your employer or otherwise, and
the adoption was not final by the end of 2011.
• The total adoption expenses you paid in 2012 were not fully reimbursed by your employer or otherwise, and the
adoption became final in 2012 or earlier.
• You adopted a child with special needs and the adoption became final in 2012.
Form 8839 (2012)