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2003

TAX CREDIT FOR DEPENDENT HEALTH BENEFITS PAID

WORKSHEET

36 M.R.S.A. § 5219-O

TAXPAYER NAME: ______________________________________________ EIN/SSN: ________________________

Note: Owners of passthrough entities (partnerships, LLCs, S corporations, trusts, etc.) making an eligible

investment, see instructions. Also, please provide name and ID number of passthrough entity on the lines below.

NAME OF PASSTHROUGH ENTITY

EIN/SSN

________________________________________________________________

________________________

Carryforward from previous years ..................................................................................

____________________

Amount paid for dependent health benefits in 2003. (See definition of “dependent health

benefits”in the instructions) .............................................................................................

____________________

Line 2 x 20% (0.20) ........................................................................................................

____________________

Number of employees in 2003 with dependent health benefits coverage ...........................

____________________

Line 4 x $125 ..................................................................................................................

____________________

Enter the lesser of line 3 or line 5 .....................................................................................

____________________

Total credit available this year: Line 1 plus line 6

(Corporations enter this amount on Form 1120ME, Schedule C, line 29k, Credit Claimed) .

____________________

Tax liability (Form 1120ME, line 7c or Form 1040ME, line 23) ..........................................

____________________

Line 8 x 50% (0.50) ........................................................................................................

____________________

10.

Credit Amount: Enter the lesser of line 7 or line 9

(enter here and on Form 1120ME, Schedule C, line 29k or Form 1040ME, Schedule A,

line 20 ) ...........................................................................................................................

____________________

11.

Carryforward: Line 7 minus line 10 plus any unused amount on Form 1120ME,

Schedule C or Form 1040ME, Schedule A. ................................................................

___________________

Rev. 12/03

Tax Credit For Dependent Health Benefits Paid Worksheet - Maine Department Of Revenue - 2003