Tax Credit For Dependent Health Benefits Paid Worksheet - 2005

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2005
TAX CREDIT FOR DEPENDENT HEALTH BENEFITS PAID
WORKSHEET
36 M.R.S.A. § 5219-O
TAXPAYER NAME: ________________________________ EIN/SSN: ______________________
Note: Owners of pass-through entities (partnerships, LLCs, S corporations, trusts, etc.) making an
eligible investment, see instructions. Also, please provide name and ID number of pass-
through entity on the lines below.
NAME OF PASS-THROUGH ENTITY
EIN/SSN
______________________________________________________
_________________________________
1. Carryforward from previous years ............................................................................ 1.
____________
2. Amount paid for dependent health benefits in 2005. (
See definition of “dependent health
) ........................................................................................... 2.
____________
benefits”in the instructions
3. Line 2 x 20% (0.20) .................................................................................................. 3.
____________
4. Number of employees in 2005 with dependent health benefits coverage .................... 4.
____________
5. Line 4 x $125 ........................................................................................................... 5.
____________
6. Enter the lesser of line 3 or line 5 .............................................................................. 6.
____________
7. Total credit available this year: Line 1 plus line 6
(
) ........ 7.
____________
Corporations enter this amount on Form 1120ME, Schedule C, line 29k, Credit Claimed
8. Tax liability (
). ...... 8.
____________
Form 1120ME, line 7a or Form 1040ME, line 23 minus Schedule A, Line 3c
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,
) ..................................................................................................................... 10. ____________
line 18
11. Carryforward: Line 7 minus line 10 plus any unused amount on Form 1120ME,
Schedule C or Form 1040ME, Schedule A. ........................................................ 11. ____________
Rev. 11.15.05

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