Tax Credit For Dependent Health Benefits Paid Worksheet - Maine Department Of Revenue - 2002
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TAX CREDIT FOR DEPENDENT HEALTH BENEFITS PAID
WORKSHEET
36 M.R.S.A. § 5219-O
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 passthrough entity on the lines below.
NAME OF PASSTHROUGH ENTITY
EIN/SSN
1.
Carryforward from previous years .................................................................................. ____________________
2.
Amount paid for dependent health benefits in 2002. (See definition of “dependent health
benefits”in the instructions) ............................................................................................. ____________________
3.
Line 2 x 20% (0.20) ........................................................................................................ ____________________
4.
Number of employees with dependent health benefits coverage ....................................... ____________________
5.
Line 4 x $125 .................................................................................................................. ____________________
6.
Enter the smaller of line 3 or line 5 .................................................................................. ____________________
7.
Total credit available this year: Line 1 plus line 6
(Corporations enter this amount on Form 1120ME, Schedule C, line 29l, Gross Amount) ... ____________________
8.
Tax liability (Form 1120ME, line 7c or Form 1040ME, line 23) .......................................... ____________________
9.
Line 8 x 50% (0.50) ........................................................................................................ ____________________
10.
Credit Amount: Enter the smaller of line 7 or line 9
(enter here and on Form 1120ME, Schedule C, line 29l or Form 1040ME, Schedule A,
line20 ) ............................................................................................................................ ____________________
11.
Carryforward: Line 7 minus line 10 plus any unused amount on Form 1120ME,
Schedule C or Form 1040ME, Schedule A. ................................................................ ____________________
Rev. 01/03
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