Tax Credit For Dependent Health Benefits Paid Worksheet 36 M.r.s.a. 5219-O - 2004

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2004
TAX CREDIT FOR DEPENDENT HEALTH BENEFITS PAID
WORKSHEET
36 M.R.S.A. § 5219-O
TAXPAYER NAME: ______________________________________________ EIN/SSN: ________________________
Note: Owners of pass-through entities (partnerships, LLCs, S corporations, trusts, etc.) making an eligible
investment, see instructions. Also, please provide name and ID number of pass-through entity on the lines below.
NAME OF PASS-THROUGH ENTITY
EIN/SSN
________________________________________________________________
________________________
1. Carryforward from previous years ........................................................................................ 1.
__________________
2. Amount paid for dependent health benefits in 2004. (See definition of “dependent health
benefits”in the instructions) ................................................................................................... 2.
__________________
3. Line 2 x 20% (0.20) .............................................................................................................. 3.
__________________
4. Number of employees in 2004 with dependent health benefits coverage ................................ 4.
__________________
5. Line 4 x $125 ........................................................................................................................ 5.
__________________
6. Enter the lesser of line 3 or line 5 ........................................................................................... 6.
__________________
7. Total credit available this year: Line 1 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, line 23 minus Schedule A, Line 3c).... 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 unused amount on Form 1120ME,
Schedule C or Form 1040ME, Schedule A...................................................................... 11. _________________
Rev. 01/05

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