Schedule Hi - Health Insurance Risk-Sharing Plan Assessments Credit - 2013
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1
2Health Insurance Risk-Sharing Plan
HI
Schedule
Assessments Credit
2013
Wisconsin Department
File with Wisconsin Form 3, 4, 5, or 5S
of Revenue
Name
Federal Employer ID Number
1
For each Health Insurance Risk-Sharing Plan (HIRSP) assessment paid in the taxable year covered by this return for
which you received a notice of HIRSP tax credit from the HIRSP Authority, complete items a through f below:
(a)
(b)
(c)
(d)
(e)
(f)
Divide Column (c)
Tax Credit
Amount of
by Column (b)
Amount for
Multiply
Assessment
Assessment
Assessment Paid
(carry to 4
Assessment
Column (d)
Date
Amount
in Taxable Year
decimal places)
Per HIRSP Notice
by Column (e)
2
Total from column (f) in line 1 above . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2
3
Health Insurance Risk-Sharing Plan assessments credit passed through from
other entities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3
4
Add lines 2 and 3. This is your 2013 Health Insurance Risk-Sharing Plan assessments
credit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4
5
Carryover of unused Health Insurance Risk-Sharing Plan assessments credit. . . . . . . . . .
5
6
Add lines 4 and 5. This is the available Health Insurance Risk-Sharing Plan
assessments credit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6
Instructions for 2013 Schedule HI
GENERAL INSTRUCTIONS
The credit is based on the assessment by the Com-
missioner of Insurance for the insurer’s proportion
Purpose of Schedule HI
of participation based on the total assessments
estimated by the Health Insurance Risk-Sharing
Use Schedule HI to claim the Health Insurance Risk-
Plan Authority.
Sharing Plan (HIRSP) assessments credit against
your Wisconsin franchise or income tax liability.
Caution: You may not claim any HIRSP credit against
your Wisconsin franchise or income tax liability
The credit is available for taxable years beginning
which you also claimed against the premium taxes
prior to January 1, 2014.
imposed under secs. 76.60, 76.63, 76.65, 76.66, or
76.67, Wis. Stats.
Who is Eligible to Claim the Credit
Credit is Income
An insurer who is required to participate in the cost
of administering the Health Insurance Risk-Sharing
The credit you compute on Schedule HI is income
Plan may be able to claim the HIRSP assessments
and must be reported on your Wisconsin franchise
credit.
or income tax return in the year computed.
IC-064
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