Schedule K-57 - Small Employer Healthcare Credit
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2K-57
KANSAS
SMALL EMPLOYER HEALTHCARE CREDIT
(Rev. 8/11)
For the taxable year beginning _________________ , 20____ ; ending _________________ , 20____ .
Name of taxpayer (as shown on return)
Social Security Number or Employer ID Number (EIN)
If partner, shareholder or member, enter name of partnership, S corporation, LLC or LLP
Employer ID Number (EIN)
Date you began participation in this plan: ___ ___ / ___ ___ / ___ ___ ___ ___ .
Those employers who started a small employer health benefit plan on or after January 1, 2005 must answer the following question:
Did this employer contribute to any health insurance premium or health savings account on behalf of an employee who is to be covered by the employer’s
‰
‰
contribution within the preceding two years of the effective date of the employer’s small employer health benefit plan?
No
Yes (If yes, you
do not qualify for this credit.)
PART A – COMPUTATION OF ELIGIBLE EMPLOYEE AMOUNT
Complete the appropriate schedule. If the employer established this plan after December 31, 2004, complete Schedule I. If the employer established this
plan prior to January 1, 2005, complete Schedule II.
SCHEDULE I
SCHEDULE II
(e)
(a)
(b)
(c)
(d)
(f)
Number of
FIRST 12 MONTHS
NEXT 12 MONTHS
NEXT 12 MONTHS
Number of
eligible
Multiply amount in (a) by
Multiply amount in (a) by
Multiply amount in (a) by
eligible
Maximum allowed.
employees for
the lesser of $70 or the
the lesser of $50 or the
the lesser of $35 or the
employees for the
Multiply amount in (e)
the month
actual amount paid per
actual amount paid per
actual amount paid per
month
by $35.
employee.
employee.
employee.
1. 1st month of tax year .....
2. 2nd month of tax year ....
3. 3rd month of tax year ....
4. 4th month of tax year ....
5. 5th month of tax year ....
6. 6th month of tax year ....
7. 7th month of tax year ....
8. 8th month of tax year ....
9. 9th month of tax year ....
10. 10th month of tax year ..
11. 11th month of tax year ...
12. 12th month of tax year ..
13. Total ...............................
If you completed SCHEDULE I, proceed to LINE 18. If you completed SCHEDULE II, proceed to LINE 14.
14. Enter actual expense for the tax period.
14.
____________________
15. Maximum credit allowed (multiply line 14 by 50% and enter the result here).
15.
____________________
16. Enter the lesser of line 13, column (f) or line 15.
16.
____________________
‰
‰
‰
‰
17. Year of participation:
1st & 2nd year
100%
3rd year
4th year
50%
5th year
25%
75%
PART B – COMPUTATION OF CREDIT
18. Credit allowable for this tax year. From SCHEDULE I – enter amount from line 13, columns (b), (c), and/or (d).
From SCHEDULE II – multiply line 16 by the appropriate percentage from line 17.
18. ____________________
K-120 Filers: STOP HERE and enter this amount on the appropriate line of Form K-120. Skip lines 19-23.
The following lines are for Form K-40 and Form K-41 filers only.
19. Enter your proportionate share percentage (see instructions).
19. ____________________
20. Your share of the credit for this year’s investment (multiply line 18 by line 19).
20. ____________________
21. Your total Kansas tax liability for this tax year after all credits other than this credit.
21. ____________________
22. Credit this tax year (enter the lesser of line 20 or line 21 here and on the appropriate line of Form K-40 or K-41).
If line 22 is less than line 20, complete PART C.
22. ____________________
PART C – COMPUTATION OF REFUND (FORM K-40 AND K-41 FILERS ONLY)
23. Refundable portion of tax credit (subtract line 22 from line 20 and enter the result here and on the refundable
credit line of Form K-40 or Form K-41.
23. ____________________
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