Form Hi - Health Insurance For Uninsured Montanans Credit - Montana Dept.of Revenue - 2010
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MONTANA
HI
Rev 08 10
2010 Health Insurance for Uninsured Montanans Credit
15-30-2367 and 15-31-132, MCA
Name (as it appears on your tax return) ________________________________________________________________
Your Social Security Number or Federal Employer Identifi cation Number
If this credit is passed through to you from a partnership or S corporation, enter the entity’s name and FEIN. If a
partnership, enter the percentage used to report the partnership’s income or loss for Montana income tax purposes; if an
S corporation, enter the pro rata share of ownership.
Name ________________________________________ FEIN _________________________ Percentage _________ %
Part I. Qualifi cations
To qualify for this credit you must answer “Yes” to each of the four statements below. A “No” answer means you are not eligible for this
credit.
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 20 or fewer 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 fi rst claimed this credit. .................................................. 4.
Yes
No
Part II. Credit Computation
This tax credit is limited to a
Column A
Column B
Column C
Column D
Column E
Column F
Column G
maximum of 10 employees.
Multiply the
Multiply the
Multiply the
Enter the
amount in
Enter the
amount in
Enter the
amount in
percentage
This is your
Column
employee’s
Column B by
number of
Column A by
of premiums
maximum
D by the
Employee
monthly
the amount
months each
the amount
paid by
monthly
amount in
premium
in Column
employee is
in Column
you as an
credit.
Column E
amount.
C and enter
insured.
E and enter
employer.
and enter
the result.
the result.
the result.
1.
%
$25
2.
%
$25
3.
%
$25
4.
%
$25
5.
%
$25
6.
%
$25
7.
%
$25
8.
%
$25
9.
%
$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.
Enter the amount from line 3 above on your appropriate tax return:
Form 2, Schedule V
Form CLT-4S, Schedule II
Form CLT-4, Schedule C
Form PR-1, Schedule II
*30110101*
3011
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