Tax Credit For Dependent Health Benefits Paid Worksheet

TAX CREDIT FOR DEPENDENT HEALTH BENEFITS PAID

WORKSHEET FOR TAX YEAR 2015

36 M.R.S. § 5219-O

TAXPAYER NAME: _____________________________________ EIN/SSN: ________________

Note: Owners of pass-through entities (such as partnerships, LLCs, S corporations, and trusts) making an eligible

investment, see instructions. Enter name and ID number of the entity on the lines below.

NAME OF PASS-THROUGH ENTITY

EIN/SSN

________________________________________________________________

____________________________

1. Number of low-income employees in 2015 with dependent health beneﬁ ts coverage ...........1. __________________

2. Line 1 x $125 ..........................................................................................................................2. __________________

3. Amount paid for dependent health beneﬁ ts in 2015 with respect to low-income employees.

(see deﬁ nition of “dependent health beneﬁ ts” in the instructions)...........................................3. __________________

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

5. Credit claimed. Enter the lesser of line 2 or line 4 .................................................................5. __________________

6. Carryforward from previous years ..........................................................................................6. __________________

7. Total credit available this year: Line 5 plus line 6 ....................................................................7. __________________

8. Tax liability (Form 1120ME, line 7a plus any credit recapture amounts included in line 7b,

or Form 1040ME, Schedule A, line 22 or Form 1041ME, Schedule A, line 18) ......................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 20 or Form 1041ME,

Schedule A, line 16) ..............................................................................................................10. __________________

That portion of the unused credit not exceeding the 2-year carryover

period may be claimed on your Maine income tax return next year.

Rev. 08/15