Form Hi - 2009 Health Insurance For Uninsured Montanans Credit
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1MONTANA
HI
Clear Form
Rev. 10-09
2009 Health Insurance for Uninsured Montanans Credit
15-30-2367 and 15-31-132, MCA
Name (as it appears on your tax return) _______________________________________________________
Your Social Security Number or Federal Employer Identification Number _____________________________
If this credit was passed through to you from a partnership or S corporation, please indicate the name and
FEIN of the partnership or S corporation and your percentage of ownership in the partnership or S corporation.
Name ____________________________________ FEIN ________________ Percent of Ownership ______ %
Part I. Qualifications
To qualify for this credit you will have to answer “Yes” to each of the four statements below. A “No” answer
means you are not eligible for this credit
For the period that I am claiming the credit:
1. I have been in business in Montana for at least 12 months. ...................................... 1.
Yes
No
2. I employ 20 or fewer employees who work at least 20 hours per week. .................... 2.
Yes
No
3. I pay at least 50% of each Montana employee’s insurance premium. ....................... 3.
Yes
No
4. It has been 36 months or less since I first claimed this credit. ................................... 4.
Yes
No
Part II. Credit Computation
This tax credit is limited to a
maximum of 10 employees.
Column A Column B Column C Column D Column E Column F Column G
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
B by the
A by the
D by the
maximum
of months
Employee
monthly
premiums
amount in
amount in
amount in
monthly
each
premium
paid by
Column C
Column E
Column E
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 F by 50% (0.50) and enter the result here. ............................................ 1.
2. Enter the total of column G here. ....................................................................................................... 2.
3. Enter the smaller of line 1 or line 2 here and on Form 2, Schedule V, for individuals; Form CLT-
4, Schedule C, for C corporations, Form CLT-4S, Schedule II, for S corporations, or Form PR-1,
Schedule II, 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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