Form Mo-A - Information To Complete Form Mo-A - Mo Department Of Revenue (Page 5 of 5) in pdf

-T

ORKSHEET FOR

ONG

ERM

ARE

NSURANCE

EDUCTION

Enter the amount paid for qualified long-term care insurance policy. ..... A) $______________

If you itemized on your federal return and your federal itemized deductions

included medical expenses, go to Line B. If not, you are eligible for the full

amount paid as shown on Line A.

Enter the amount from Federal Schedule A, Line 4. ................................ B) $______________

Enter the amount from Federal Schedule A, Line 1. ................................ C) $______________

Enter the amount of qualified long-term care included on Line C. ..........D) $______________

Subtract Line D from Line C. .................................................................. E) $______________

Subtract Line E from Line B. If amount is less than zero, enter “0”. ...... F) $______________

Subtract Line F from Line A. ................................................................... G) $______________

Attach a copy of your Federal Form 1040 (pages 1 and 2) and Federal Schedule A (if you itemized your deductions).

Back to MO-1040, page 1

QUALIFIED HEALTH INSURANCE PREMIUMS WORKSHEET FOR MO-A, LINE 11

Complete this worksheet if you included health insurance premiums paid as an itemized deduction or had health insurance premiums withheld from your social

security benefits.

If you had premiums withheld from your social security benefits, complete Lines 1 through 4 to determine your taxable percentage of social security income and

the corresponding taxable portion of your health insurance premiums included in your taxable income.

1. Enter amount from Line 14a (federal Form 1040A) or 20a (federal Form 1040). If $0, skip to Line 6 and enter

your total health insurance premiums paid.

1. ___________

2. Enter amount from Line 14b (federal Form 1040A) or 20b (federal Form 1040).

2. ___________

3. Divide Line 2 by Line 1

3. ___________ %

Yourself

Spouse

4. Enter the health insurance premiums withheld from your social security income.

4Y. ___________