Employer-Provided Long-Term Care Benefits Credit Worksheet

Employer-Provided Long-Term Care Benefits Credit Worksheet - 2002

2002

EMPLOYER-PROVIDED LONG-TERM CARE

BENEFITS CREDIT WORKSHEET

36 M.R.S.A. § 5217-C

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 the passthrough entity on the

lines below.

EIN/SSN

NAME OF PASSTHROUGH ENTITY

Number of employees with long-term care insurance coverage provided by the employer ______________

Line 1 x $100 .............................................................................................................

______________

Costs incurred by the employer in providing long-term care insurance coverage for its

employees during the taxable year ...............................................................................

______________

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

______________

Enter the smaller of line 2 or line 4 ( but if greater than $5,000, enter only $5,000) .......

______________

Credit carried forward from previous tax years. See instructions .................................

______________

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 13. ....................................................................................................

______________

Rev. 1/03

Employer-Provided Long-Term Care Benefits Credit Worksheet - 2002