Montana Form Hi - Montana Disability Insurance For Uninsured Montanans Credit - 1999
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1MONTANA
Form HI
Rev. 8-99
MONTANA DISABILITY INSURANCE FOR UNINSURED MONTANANS CREDIT
Credit available to certain employers who make disability insurance available to employees
MCA 15-30-129
Instructions on back
Name (as shown on Form 2)
FEIN:
PART I
Note: If you have contributed to any premiums for limited disability insurance on behalf of an employee within the last 12
months you do not qualify.
Have you been in business in Montana for at least 12 months?
_____Yes _____No
Do you employ 20 or fewer employees working at least 20 hours per week?
_____Yes _____No
Do you pay at least 50% of each Montana employee’s insurance premium?
_____Yes _____No
If you answer no to any of the above questions, do not complete this form. You do not qualify for the credit.
PART II
The credit is limited to a maximum of 10 employees.
Column 1
Column 2
Column 3
Column 4
Column 5
Column 6
Column 7
% of
Number of
Monthly
Premiums
Multiply
Months Each
Multiply
Multiply
Premium
Paid by
Column 2 X
Employee
Column 1 X
Column 4 X
Employee
Amount
Employer
Column 3
Insured
Column 5
Column 5
1.
$25
2.
$25
3.
$25
4.
$25
5.
$25
6.
$25
7.
$25
8.
$25
9.
$25
10.
$25
TOTAL
1. Multiply total of column 6 by 50% (.50)................................................................................................$__________
2. Enter total from column 7......................................................................................................................$__________
3. Enter the smaller of line 1 or line 2. This is your credit. Enter this amount
on Form 2A, Schedule II ........................................................................................................$__________
121
Attach a copy of this form to your return
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