Form Hi - Health Insurance For Uninsured Montanans Credit - 2015

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MONTANA
Clear Form
HI
2015 Health Insurance
Rev 06 15
for Uninsured Montanans Credit
15-30-2367 and 15-31-132, MCA
Name (as it appears on your Montana tax return)
Social Security
Federal Employer
OR
-
-
-
Number
Identification Number
Part I. Partners in a Partnership or Shareholders of an S Corporation
Enter your portion of the health insurance for uninsured Montanans credit here. See
$_____________________
instructions.
Business Name of Partnership or S Corporation
Federal Employer
-
Identification Number
___________________________________________________
Part II. Qualifications
To qualify for this credit, you must answer yes to all of the four statements below. 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 at least 2 but not more than 20 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 first claimed this credit ...............................................4.  Yes
 No
Part III. Credit Computation. This tax credit is limited to a maximum of 10 employees.
Column A
Column B
Column C
Column D
Column E
Column F
Column G
Enter the
Multiply the
Multiply the
Enter the
Enter the
Multiply the
percentage
This is your
amount in
amount in
Employee
employee’s
number of
amount in
of premiums
maximum
Column B
Column
monthly
months each
Column A by
paid by
monthly
by the
D by the
premium
employee is
the amount
you as an
credit.
amount in
amount in
amount.
insured.
in Column E.
employer.
Column C.
Column E.
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.
Where to Report Your Credit
► Form 2, Schedule V
► Form CLT-4S, Schedule II
► Form CIT, Schedule C
► Form PR-1, Schedule II
If you file your Montana tax return electronically, you do not need to mail this form to us unless we ask you for a copy. When you file electronically, you
represent that you have retained the required documents in your tax records and will provide them upon the department’s request.

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