Instructions For Form 8941 - Credit For Small Employer Health Insurance Premiums - 2010 Page 6
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8Worksheet 1. Information Needed To Complete
Worksheet 2. Full-Time Equivalent Employees
Line 1 and Worksheets 2 and 3
(FTEs)
If you need more rows, use a separate sheet and include the
1. Enter the total employee hours of service
additional amounts in the totals below.
from Worksheet 1, column (b) . . . . . . . . 1.
(a)
(b)
(c)
2. Hours of service per FTE . . . . . . . . . . . 2.
2,080
Individuals
Employee
Employee
3. Full-time equivalent employees. Divide
Considered
Hours of
Wages
line 1 by line 2. If the result is not a
Employees
Service
Paid
whole number (0, 1, 2, etc.), generally
1.
round the result down to the next lowest
whole number. However, if the result is
2.
less than one, enter 1. Report this
amount on Form 8941, line 2 . . . . . . . . . 3.
3.
4.
Line 3
5.
Enter the average annual wages shown on line 3 of
6.
Worksheet 3. For details, see Average Annual Wage
Limitation on page 2.
7.
Worksheet 3. Average Annual Wages
8.
9.
1. Enter the total employee wages paid
10.
from Worksheet 1, column (c) . . . . . . . . 1.
11.
2. Enter FTEs from Worksheet 2, line 3 . . . 2.
3. Average annual wages. Divide line 1 by
12.
line 2. If the result is not a multiple of
13.
$1,000 ($1,000, $2,000, $3,000, etc.),
round the result down to the next lowest
14.
multiple of $1,000. Report this amount
15.
on Form 8941, line 3 . . . . . . . . . . . . . . 3.
16.
Line 4
17.
Enter the total employer premiums paid shown in column
18.
(b) of Worksheet 4. For details, see Employer Premiums
Paid on page 3.
19.
Line 5
20.
Enter the total employer-state-average premiums shown
21.
in column (c) of Worksheet 4. For details, see State
22.
Average Premium Limitation on page 4.
Instructions for Worksheet 4
23.
24.
Column (a). Enter the name or other identifying
information for each individual listed in column (a) of
25.
Worksheet 1 who was enrolled in health insurance
coverage you provided to employees during the tax year
under a qualifying arrangement. For details, see Health
Totals:
Insurance Coverage and Qualifying Arrangement on
page 3.
Column (b). Enter the total employer premiums paid for
Line 2
the tax year for each employee listed in column (a). For
Enter the number of full-time equivalent employees
details, see Employer Premiums Paid on page 3.
shown on line 3 of Worksheet 2. For details, see FTE
Column (c). Enter, for each employee listed in column
Limitation on page 2.
(a), the premiums you would have paid if the employee
had enrolled in a plan or plans with a total premium equal
to the average premium for the small group market in the
state in which the employee works. For details, see State
Average Premium Limitation on page 4.
Do not complete column (d) if Form 8941, line 12,
!
is zero.
CAUTION
Column (d). Enter the amount from column (b) of
Worksheet 1 for each employee listed in column (a) of
Worksheet 4.
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Parent category: Financial