Montana Form Hi - 2006 Health Insurance For Uninsured Montana Credit
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12006 Health Insurance for Uninsured Montanans Credit
MONTANA
15-30-129 and 15-31-132, MCA
HI
Rev. 12-06
__________________________________________________
Name (as it appears on your tax return)
__________________________
Your Social Security Number or Federal Employer Identification Number
If this credit is a pass-through to you from a partnership or S. corporation enter the name, FEIN and your
percentage of ownership in the partnership or S. corporation.
Name __________________________________
FEIN__________________ % of Ownership _______
Part I Qualifications
To qualify for this credit you will have to answer “yes” to each of the three statements below. A “no” answer
means you are not eligible for this credit.
•
.......................
I have been in business in Montana for at least 12 months.
Yes
No
•
.......
I employ 20 or fewer employees who work at least 20 hours per week.
Yes
No
•
........
I pay at least 50% of each Montana employee’s insurance premiums.
Yes
No
Part II Credit Computation
This tax credit is limited to a maximum of 10 employees.
Column 1
Column 2
Column 3
Column 4
Column 5
Column 6
Column 7
Multiply the
Multiply the
Multiply the
Enter the
amount in
amount in
amount in
Enter the
Enter the
percentage
Column 2
Column 1
Column 4
This is your
number of
employee’s
of
by the
by the
by the
Employee
maximum
months
monthly
amount in
amount in
amount in
premiums
monthly
each
premium
paid by you
Column 3
Column 5
Column 5
credit.
employee is
amount.
as an
and enter
and enter
and enter
insured.
employer.
the result
the result
the result
here.
here.
here.
1.
$25
2.
$25
3.
$25
4.
$25
5.
$25
6.
$25
7.
$25
8.
$25
9.
$25
10.
$25
Total
..................................
1. Multiply the total of column 6 by .50 (50%) and enter the result here.
1
......................................................................................
2. Enter the total of column 7 here.
2
3. Enter the smaller of line 1 or line 2 here and on Form 2, Schedule V, line 7 for individuals;
Form CLT-4, Schedule C, line 6 for C. corporations, Form CLT-4S, Schedule II, line 3 for S.
corporations, or Form PR-1, Schedule II, line 3 for Partnerships. This is your Health
.................................................................
Insurance for Uninsured Montanans Credit.
3
When you file your Montana income tax return electronically, you represent that you have retained all
documents required as a tax record and that you will provide a copy to the department upon request.
121
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