Montana Form Hi - Health Insurance For Uninsured Montanans Credit

1 2

MONTANA

2012 Health Insurance

Rev 03 12

for Uninsured Montanans Credit

15-30-2367 and 15-31-132, MCA

Name (as it appears on your Montana tax return)

Social Security

Federal Employer

X X X X X X X X X

Number

Identification Number

Part I. Partners in a Partnership or Shareholders of an S Corporation

Enter your portion of the health insurance for uninsured Montanans credit here. See

$_____________________

instructions.

Business Name of Partnership or S Corporation

Federal Employer

Identification Number

___________________________________________________

Part II. Qualifications

To qualify for this credit, you must answer yes to all of the four statements below. For the period that I am claiming the credit:

1. I have been in business in Montana for at least 12 months ..................................................1.  Yes

 No

2. I employ at least 2 but not more than 20 employees who work at least 20 hours per week ....2.  Yes

 No

3. I pay at least 50% of each Montana employee’s insurance premium ...................................3.  Yes

 No

4. It has been 36 months or less since I first claimed this credit ...............................................4.  Yes

 No

Part III. Credit Computation. This tax credit is limited to a maximum of 10 employees.

Column A

Column B

Column C

Column D

Column E

Column F

Column G

Enter the

Multiply the

Enter the

Multiply the

percentage

This is your

amount in

Employee

employee’s

number of

amount in

of premiums

maximum

Column B

Column

monthly

months each

Column A by

paid by

monthly

by the

D by the

premium

employee is

the amount

you as an

credit.

amount in

amount.

insured.

in Column E.

employer.

Column C.

Column E.

$25

10.

$25

Total

1. Multiply the total of Column F by 50% (0.50) and enter the result...............................................................1.

2. Enter the total of Column G .........................................................................................................................2.

3. Enter the smaller of line 1 or line 2. This is your health insurance for uninsured Montanans credit ...3.

Where to Report Your Credit

► Form 2, Schedule V

► Form CLT-4S, Schedule II

► Form CLT-4, Schedule C

► Form PR-1, Schedule II

If you file your Montana tax return electronically, you do not need to mail this form to us unless we ask you for a copy. When you file electronically, you

represent that you have retained the required documents in your tax records and will provide them upon the department’s request.

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