Form 8941 - Credit For Small Employer Health Insurance Premiums - 2017
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18941
OMB No. 1545-2198
Credit for Small Employer Health Insurance Premiums
2017
Form
Attach to your tax return.
▶
Department of the Treasury
Go to for instructions and the latest information.
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Attachment
65
Internal Revenue Service
Sequence No.
Name(s) shown on return
Identifying number
A
Did you pay premiums during your tax year for employee health insurance coverage you provided through a Small Business
Health Options Program (SHOP) Marketplace (or do you qualify for an exception to this requirement)? See instructions.
Yes. Enter Marketplace Identifier (if any):
No. Stop. Do not file Form 8941 (see instructions for an exception that may apply to a partnership, S corporation,
cooperative, estate, trust, or tax-exempt entity)
Enter the employer identification number (EIN) used to report employment taxes for individuals included on line 1 below if
B
different from the identifying number listed above
C
Does a tax return you (or any predecessor) filed for a tax year beginning in 2014 or 2015 include a Form 8941 with line A
checked "Yes" and line 12 showing a positive amount?
Yes. Stop. Do not file Form 8941 (see instructions for an exception that may apply to a partnership, S corporation,
cooperative, estate, trust, or tax-exempt entity) (also see instructions for information about the credit period limitation)
No.
Caution: See the instructions and complete Worksheets 1 through 7 as needed.
1
Enter the number of individuals you employed during the tax year who are considered
employees for purposes of this credit (total from Worksheet 1, column (a))
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1
2
Enter the number of full-time equivalent employees (FTEs) you had for the tax year (from
Worksheet 2, line 3). If you entered 25 or more, skip lines 3 through 11 and enter -0- on line 12
2
Average annual wages you paid for the tax year (from Worksheet 3, line 3). This amount must be a
3
3
multiple of $1,000. If you entered $53,000 or more, skip lines 4 through 11 and enter -0- on line 12
4
Premiums you paid during the tax year for employees included on line 1 for health insurance
coverage under a qualifying arrangement (total from Worksheet 4, column (b))
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4
5
Premiums you would have entered on line 4 if the total premium for each employee equaled the
average premium for the small group market in which the employee enrolls in health insurance
coverage (total from Worksheet 4, column (c)) .
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6
Enter the smaller of line 4 or line 5
6
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7
Multiply line 6 by the applicable percentage:
• Tax-exempt small employers, multiply line 6 by 35% (0.35)
7
• All other small employers, multiply line 6 by 50% (0.50) .
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8
If line 2 is 10 or less, enter the amount from line 7. Otherwise, enter the amount from Worksheet 5, line 6
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If line 3 is $26,000 or less, enter the amount from line 8. Otherwise, enter the amount from
Worksheet 6, line 7
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9
10
Enter the total amount of any state premium subsidies paid and any state tax credits available to
you for premiums included on line 4. See instructions
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10
11
Subtract line 10 from line 4. If zero or less, enter -0- .
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12
Enter the smaller of line 9 or line 11 .
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13
If line 12 is zero, skip lines 13 and 14 and go to line 15. Otherwise, enter the number of
employees included on line 1 for whom you paid premiums during the tax year for health
insurance coverage under a qualifying arrangement (total from Worksheet 4, column (a)) .
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14
Enter the number of FTEs you would have entered on line 2 if you only included employees
included on line 13 (from Worksheet 7, line 3) .
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14
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Credit for small employer health insurance premiums from partnerships, S corporations,
cooperatives, estates, and trusts (see instructions) .
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15
16
Add lines 12 and 15. Cooperatives, estates, and trusts, go to line 17. Tax-exempt small
employers, skip lines 17 and 18 and go to line 19. Partnerships and S corporations, stop here
and report this amount on Schedule K. All others, stop here and report this amount on Form
3800, Part III, line 4h .
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16
17
Amount allocated to patrons of the cooperative or beneficiaries of the estate or trust (see instructions)
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18
Cooperatives, estates, and trusts, subtract line 17 from line 16. Stop here and report this amount
on Form 3800, Part III, line 4h .
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Enter the amount you paid in 2017 for taxes considered payroll taxes for purposes of this credit.
See instructions .
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Tax-exempt small employers, enter the smaller of line 16 or line 19 here and on Form 990-T, line 45f
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8941
For Paperwork Reduction Act Notice, see separate instructions.
Cat. No. 37757S
Form
(2017)
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