Employer-Provided Long-Term Care Benefits Credit Worksheet

Employer-Provided Long-Term Care Benefits Credit Worksheet - 2004

2004

EMPLOYER-PROVIDED LONG-TERM CARE

BENEFITS CREDIT WORKSHEET

36 M.R.S.A. § 5217-C

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 the pass-through entity on

the lines below.

EIN/SSN

NAME OF PASS-THROUGH ENTITY

____________________________________________________________

_____________________

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

employer .................................................................................................................... 1. ______________

Line 1 x $100 ............................................................................................................. 2. ______________

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

for its employees during the taxable year ...................................................................... 3. ______________

Line 3 x 20% (0.20) ................................................................................................... 4. ______________

Enter the lesser of line 2, line 4 or $5,000 .................................................................... 5. ______________

Credit carried forward from previous tax years. See instructions ................................. 6. ______________

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 18. .................................................................................................... 7. ______________

Rev. 01/05

Employer-Provided Long-Term Care Benefits Credit Worksheet - 2004