Tax Credit For Dependent Health Benefits Paid Worksheet For Tax Year 2012 printable pdf download

Tax Credit For Dependent Health Benefits Paid Worksheet For Tax Year 2012

TAX CREDIT FOR DEPENDENT HEALTH BENEFITS PAID

WORKSHEET FOR TAX YEAR 2012

36 M.R.S.A. § 5219-O

TAXPAYER NAME: _____________________________________ EIN/SSN: ________________

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

investment, see instructions. Enter name and ID number of the entity on the lines below.

NAME OF PASS-THROUGH ENTITY

EIN/SSN

________________________________________________________________

____________________________

1. Number of low-income employees in 2012 with dependent health beneﬁ ts coverage ...........1. __________________

2. Line 1 x $125 ..........................................................................................................................2. __________________

3. Amount paid for dependent health beneﬁ ts in 2012 with respect to low-income employees.

(see deﬁ nition of “dependent health beneﬁ ts” in the instructions)...........................................3. __________________

4. Line 3 x 20% (0.20) ................................................................................................................4. __________________

5. Credit claimed. Enter the lesser of line 2 or line 4 .................................................................5. __________________

6. Carryforward from previous years. (Excess credit may only be carried over for 2 years) .....6. __________________

7. Total credit available this year: Line 5 plus line 6

(Corporations enter this amount on Form 1120ME, Schedule C, line 29k, Credit Claimed) ...7. __________________

8. Tax liability (Form 1120ME, line 7a or Form 1040ME, Schedule A, line 20) ...........................8. __________________

9. Line 8 x 50% (0.50) ................................................................................................................9. __________________

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 18) ..................................................................................................................................10. __________________

That portion of the unused credit not exceeding the 2-year carryover

period may be claimed on your Maine income tax return next year.

Rev. 11/12