Form 8941 (2010) Credit For Small Employer Health Insurance Premiums
Download a blank fillable Form 8941 (2010) Credit For Small Employer Health Insurance Premiums in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form 8941 (2010) Credit For Small Employer Health Insurance Premiums with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
18941
OMB No. 1545-2198
Credit for Small Employer Health Insurance Premiums
Form
2010
See separate instructions.
▶
Department of the Treasury
Attachment
Attach to your tax return.
63
▶
Internal Revenue Service
Sequence No.
Name(s) shown on return
Identifying number
1
Enter the number of individuals you employed during the tax year who are considered
employees for purposes of this credit (see instructions) .
.
.
.
.
.
.
.
.
.
.
.
.
.
1
2
Enter the number of full-time equivalent employees you had for the tax year (see instructions). If
2
you entered 25 or more, skip lines 3 through 11 and enter -0- on line 12 .
.
.
.
.
.
.
.
3
Average annual wages you paid for the tax year (see instructions). If you entered $50,000 or
more, skip lines 4 through 11 and enter -0- on line 12
.
.
.
.
.
.
.
.
.
.
.
.
.
.
3
4
Premiums you paid during the tax year for employees included on line 1 for health insurance
4
coverage under a qualifying arrangement (see instructions)
.
.
.
.
.
.
.
.
.
.
.
.
5
Premiums you would have entered on line 4 if the total premium for each employee equaled the
average premium for the small group market in which you offered health insurance coverage
5
(see instructions)
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
6
6
Enter the smaller of line 4 or line 5
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
7
Multiply line 6 by the applicable percentage:
• Tax-exempt small employers, multiply line 6 by 25% (.25)
• All other small employers, multiply line 6 by 35% (.35)
.
.
.
.
.
.
.
.
.
.
.
.
.
7
8
8
If line 2 is 10 or less, enter the amount from line 7. Otherwise, see instructions .
.
.
.
.
.
9
9
If line 3 is $25,000 or less, enter the amount from line 8. Otherwise, see instructions .
.
.
.
10
Enter the total amount of any state premium subsidies paid and any state tax credits available to
you for premiums included on line 4 (see instructions) .
.
.
.
.
.
.
.
.
.
.
.
.
.
10
11
11
Subtract line 10 from line 4. If zero or less, enter -0- .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
12
Enter the smaller of line 9 or line 11 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
12
13
If line 12 is zero, skip lines 13 and 14 and go to line 15. Otherwise, enter the number of
employees included on line 1 for whom you paid premiums during the tax year for health
insurance coverage under a qualifying arrangement (see instructions) .
.
.
.
.
.
.
.
.
13
14
Enter the number of full-time equivalent employees you would have entered on line 2 if you only
14
included employees included on line 13 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
15
Credit for small employer health insurance premiums from partnerships, S corporations,
cooperatives, estates, and trusts (see instructions) .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
15
16
Add lines 12 and 15. Partnerships and S corporations, stop here and report this amount on
16
Schedule K; all others, go to line 17 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
17
Credit for small employer health insurance premiums included on line 16 from passive activities
(see instructions)
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
17
18
18
Subtract line 17 from line 16 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
19
Credit for small employer health insurance premiums allowed for 2010 from a passive activity
(see instructions)
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
19
20
20
Carryback of the credit for small employer health insurance premiums from 2011 .
.
.
.
.
21
Add lines 18 through 20. Cooperatives, estates, and trusts, go to line 22. Tax-exempt small
employers, skip lines 22 and 23 and go to line 24. All others, stop here and report this amount
on Form 3800, line 29h
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
21
22
Amount allocated to patrons of the cooperative or beneficiaries of the estate or trust (see
instructions) .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
22
23
Cooperatives, estates, and trusts, subtract line 22 from line 21. Stop here and report this amount
23
on Form 3800, line 29h
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
24
Enter the amount you paid in 2010 for taxes considered payroll taxes for purposes of this credit
(see instructions)
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
24
25
Tax-exempt small employers, enter the smaller of line 21 or line 24 here and on Form 990-T,
line 44f .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
25
8941
For Paperwork Reduction Act Notice, see separate instructions.
Cat. No. 37757S
Form
(2010)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial