Employer-Provided Long-Term Care Benefits Tax Credit Worksheet For Tax Year 2006

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EMPLOYER-PROVIDED LONG-TERM CARE BENEFIT
TAX CREDIT WORKSHEET FOR TAX YEAR 2006
36 M.R.S.A. § 5217-C
TAXPAYER NAME: _____________________________________ EIN/SSN: ________________
Note: Owners of pass-through entities (partnerships, LLCs, S corporations, trusts, etc.) making an eligible
investment, see instructions. Also, please provide name and ID number of the pass-through entity on the
lines below.
NAME OF PASS-THROUGH ENTITY
EIN/SSN
________________________________________________________________
____________________________
1.
Number of employees with eligible long-term care insurance coverage provided
by the employer .....................................................................................................................1. __________________
2.
Line 1 x $100 ..........................................................................................................................2. __________________
3.
Costs incurred by the employer in providing eligible long-term care insurance
coverage for its employees during the taxable year ...............................................................3. __________________
4.
Line 3 x 20% (0.20) .................................................................................................................4. __________________
5.
Enter the lesser of line 2, line 4 or $5,000 ..............................................................................5. __________________
6.
Credit carried forward from previous tax years. See instructions ...........................................6. __________________
7.
Total credit available this year (line 5 plus line 6). Corporate taxpayers, enter on
Form 1120ME, Schedule C, line 29d. Individual taxpayers, enter on Form
1040ME, Schedule A, line 18. .................................................................................................7. __________________
Rev. 01/07

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