US Internal Revenue Service: f8839 - 2004

5
TLS, have you I.R.S. SPECIFICATIONS TO BE REMOVED BEFORE PRINTING

transmitted all R Action Date Signature
text files for this INSTRUCTIONS TO PRINTERS
cycle update? FORM 8839, PAGE 1 of 2
MARGINS: TOP 13 mm (1⁄2 "), CENTER SIDES. PRINTS: HEAD TO HEAD O.K. to print
PAPER: WHITE WRITING, SUB. 20. INK: BLACK
FLAT SIZE: 203 mm (8") 279 mm (11")
Date PERFORATE: NONE Revised proofs
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT requested
8839
OMB No. 1545-1552
Qualified Adoption Expenses
Form
Department of the Treasury

䊳 Attach to Form 1040 or 1040A. 2004
Attachment
䊳 See separate instructions.
Internal Revenue Service (99) Sequence No. 38
Name(s) shown on return Your social security number
Before you begin: You need to understand the following terms. See Definitions on page 1 of the instructions.
● Eligible Child ● Employer-Provided Adoption Benefits ● Qualified Adoption Expenses
Part I Information About Your Eligible Child or Children—You must complete this part. See page 2 of the
instructions for details, including what to do if you need more space.
Check if child was—
1 (b) (f)
(a) (c) (d) (e)
Child’s year born before a child a Child’s
Child’s name
of birth 1987 and with special foreign identifying number
First Last was disabled needs child
Child
1
Child
2
Caution: If the child was a foreign child, see Special rules in the instructions for line 1, column (e), that begin on page 2, 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
Before you begin: If you are filing Form 1040 and claiming the mortgage interest credit (see the instructions for Form 1040,
line 53), complete Form 8396, Mortgage Interest Credit.
Child 1 Child 2
2 Maximum credit per child 2 $10,390 00 $10,390 00

3 Did you file Form 8839 for a prior year?

No. Enter -0-.
Yes. See page 3 of the instructions 3
for the amount to enter.
4 Subtract line 3 from line 2 4
5 Enter your total qualified adoption
expenses (see page 3 of the instructions) 5
Caution: Your qualified adoption expenses
may not be equal to the adoption expenses
you paid in 2004.
6 Enter the smaller of line 4 or line 5 6
7 Add the amounts on line 6. If zero, skip lines 8 through 11 and enter -0- on line 12 7
8 Enter your modified adjusted gross income (see page 4 of the instructions) 8
9 Is line 8 more than $155,860?
No. Skip lines 9 and 10, and enter -0- on line 11.
Yes. Subtract $155,860 from line 8 9
10 Divide line 9 by $40,000. Enter the result as a decimal (rounded to at least three places). Do
not enter more than “1.000” 10 .
11 Multiply line 7 by line 10 11
13 Credit carryforward from prior years. Enter the amount, if any, from line 23 of your Credit
Carryforward Worksheet on page 4 of the 2003 Form 8839 instructions 13
14 Add lines 12 and 13 14
15 Enter the amount from Form 1040, line 45, or Form 1040A, line 28 15

16 1040 filers: Enter the total of the amounts from Form
1040, lines 46 through 51, plus any mortgage
interest credit from Form 8396, line 11. 16
1040A filers: Enter the total of the amounts from Form
1040A, lines 29 through 33.
18 Adoption credit. Enter the smaller of line 14 or line 17 here and on Form 1040, line 52, or
Form 1040A, line 34. If line 17 is smaller than line 14, you may have a credit carryforward
(see page 4 of the instructions) 18
For Paperwork Reduction Act Notice, see page 5 of the instructions. Cat. No. 22843L Form 8839 (2004)
5
I.R.S. SPECIFICATIONS TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM 8839, PAGE 2 of 2
MARGINS: TOP 13 mm (1⁄2 "), CENTER SIDES. PRINTS: HEAD TO HEAD
PAPER: WHITE WRITING, SUB. 20. INK: BLACK
FLAT SIZE: 203 mm (8") 279 mm (11")
PERFORATE: NONE
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT
Form 8839 (2004) Page 2

Part III Employer-Provided Adoption Benefits
Child 1 Child 2
19 Maximum exclusion per child 19 $10,390 00 $10,390 00
20 Did you receive employer-provided

adoption benefits for a prior year?

No. Enter -0-.
Yes. See page 4 of the instructions 20
for the amount to enter.
22 Enter the total amount of

employer-provided adoption benefits you
received in 2004. This amount should be
shown in box 12 of your 2004 Form(s) W-2
with code T 22
23 Add the amounts on line 22 23
24 Enter the smaller of line 21 or line 22. But

if the child was a child with special needs
and the adoption became final in 2004,
enter the amount from line 21. 24
25 Add the amounts on line 24. If zero, skip lines 26 through 29, enter
-0- on line 30, and go to line 31 25
26 Enter your modified adjusted gross
income (from the worksheet on
page 5 of the instructions) 26
27 Is line 26 more than $155,860?

No. Skip lines 27 and 28, and
enter -0- on line 29.
Yes. Subtract $155,860 from
line 26 27
28 Divide line 27 by $40,000. Enter the result as a decimal (rounded
to at least three places). Do not enter more than “1.000” 28 .
29 Multiply line 25 by line 28 29
30 Excluded benefits. Subtract line 29 from line 25 30
31 Taxable benefits. Is line 30 more than line 23?

No. Subtract line 30 from line 23. Also, include this amount, if more than zero, on
line 7 of Form 1040 or 1040A. On the line next to line 7, enter “AB.”
Yes. Subtract line 23 from line 30. Enter the result as a negative number. Reduce the total
you would enter on line 7 of Form 1040 or 1040A by the amount on Form 8839, line
31, and enter the result on line 7 of Form 1040 or 1040A. On the line next to line 7, 31
enter “SNE.”
You may be able to claim the adoption credit in Part II on the front of this form if either of the following apply.
● The total adoption expenses you paid in 2004 were not fully reimbursed by your employer and the adoption
TIP
became final in 2004 or earlier.
● You adopted a child with special needs and the adoption became final in 2004.
Form 8839 (2004)

US Internal Revenue Service: f8839 - 2004

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5

TLS, have you I.R.S. SPECIFICATIONS TO BE REMOVED BEFORE PRINTING

Department of the Treasury

2 Maximum credit per child 2 $10,390 00 $10,390 00

Form 8839 (2004) Page 2

19 Maximum exclusion per child 19 $10,390 00 $10,390 00

20 Did you receive employer-provided

21 Subtract line 20 from line 19 21

22 Enter the total amount of

23 Add the amounts on line 22 23

24 Enter the smaller of line 21 or line 22. But

27 Is line 26 more than $155,860?

29 Multiply line 25 by line 28 29

30 Excluded benefits. Subtract line 29 from line 25 30

31 Taxable benefits. Is line 30 more than line 23?

Form 8839 (2004)

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