Employer-Provided Long-Term Care Benefits Tax Credit Worksheet For Tax Year 2012 printable pdf download

Employer-Provided Long-Term Care Benefits Tax Credit Worksheet For Tax Year 2012

EMPLOYER-PROVIDED LONG-TERM CARE BENEFITS

TAX CREDIT WORKSHEET FOR TAX YEAR 2012

36 M.R.S.A. § 5217-C

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

________________________________________________________________

____________________________

Number of employees with eligible long-term care insurance coverage provided

by the employer .....................................................................................................................1. __________________

Line 1 x $100 ..........................................................................................................................2. __________________

Costs incurred in providing eligible long-term care insurance

coverage for employees during the taxable year ....................................................................3. __________________

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

Credit claimed. Enter the lowest of line 2, line 4 or $5,000 ....................................................5. __________________

Credit carried forward from previous tax years (see instructions) ...........................................6. __________________

Total credit available this year (line 5 plus line 6). Corporate taxpayers, enter on

Form 1120ME, Schedule C, line 29d. Individual taxpayers, enter on Form 1040ME,

Schedule A, line 18 .................................................................................................................7. __________________

The credit is limited to the tax liability, excluding minimum tax, of the taxpayer.

Any unused credit may be carried forward for up to 15 years.

Rev. 11/12