Tax Credit For Dependent Health Benefits Paid Worksheet For Tax Year 2011

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TAX CREDIT FOR DEPENDENT HEALTH BENEFITS PAID
WORKSHEET FOR TAX YEAR 2011
36 MRSA § 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 2011 with dependent health benefi ts coverage ...........1. __________________
2. Line 1 x $125 ..........................................................................................................................2. __________________
3. Amount paid for dependent health benefi ts in 2011 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. __________________
11. Carryforward: Line 7 minus line 10 plus any amount on line 10 not used on
Form 1120ME, Schedule C or Form 1040ME, Schedule A as a result of claiming other
Maine credits fi rst or because the amount on line 10 exceeds your Maine tax liability.
(see instructions.) .................................................................................................................. 11. __________________
Rev. 2/12

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