Montana Form Hi - 2007 Health Insurance For Uninsured Montana Credit
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1MONTANA
Clear Form
HI
Rev. 11-07
2007 Health Insurance for Uninsured Montanans Credit
15-30-129 and 15-31-132, MCA
Name (as it appears on your tax return) _______________________________________________________
Your Social Security Number or Federal Employer Identifi cation 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. Qualifi cations
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
Column
Column
This is your
number
employee’s
of
2 by the
1 by the
4 by the
maximum
of months
Employee
monthly
premiums
amount in
amount in
amount in
monthly
each
premium
paid by
Column 3
Column 5
Column 5
credit.
employee
amount.
you as an
and enter
and enter
and enter
is 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 fi le 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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