Montana Form Hi - Health Insurance For Uninsured Montanans Credit - 2004
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1MONTANA
HI
Rev. 8-04
Health Insurance For Uninsured Montanans Credit
Credit available to certain employers who provide health insurance available to employees
15-30-129 and 15-31-132, MCA
Instructions on back
Name (as shown on Form 2 for Individuals and Form CLT-4 for Corporations)
FEIN
SSN
Part I
Have you been in business in Montana for at least 12 months?
_____Yes _____No
Do you employ 20 or fewer employees working at least 20 hours per week?
_____Yes _____No
Do you pay at least 50% of each Montana employee’s insurance premium?
_____Yes _____No
If you answer no to any of the above questions, do not complete this form. You do not qualify for the credit.
Part II
The credit is limited to a maximum of 10 employees.
Column 1
Column 2
Column 3
Column 4
Column 5
Column 6
Column 7
Number of
% of
Multiply
Multiply
Multiply
Monthly
Premiums
Months Each
Column 1 X
Column 2 X
Column 4 X
Employee
Premium
Paid by
Employee
Column 5
Column 5
Column 3
Amount
Employer
Insured
1.
$25
2.
$25
3.
$25
4.
$25
5.
$25
6.
$25
7.
$25
8.
$25
9.
$25
10.
$25
Total
$__________
1. Multiply total of column 6 by 50% (.50).............................................................................
$__________
2. Enter total from column 7..................................................................................................
3. Enter the smaller of line 1 or line 2. This is your credit. For individuals enter this amount on
$__________
Form 2A, Schedule II. For corporations enter this amount on Form CLT-4, Schedule C.................
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.
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