Electronic Medical Records
EM
Schedule
Credit
2013
Wisconsin Department
Enclose with Form 1, 1NPR, 2, 3, 4, 4T, 5, or 5S
of Revenue
Name
Identifying Number
1
Fill in the amount of electronic medical records credit allocated to you by the
Wisconsin Department of Revenue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
.00
2
Electronic medical records credit passed through from other entities
2a Entity Name
FEIN
Amount 2a
.00
2b Entity Name
FEIN
Amount 2b
.00
2c Entity Name
FEIN
Amount 2c
.00
2d Entity Name
FEIN
Amount 2d
.00
.00
2e Total pass through credits from additional schedule . 2e
2f Total credits (add lines 2a through 2e) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2f
.00
3
Add the amounts on lines 1 and 2f . This is your 2013 electronic medical records
credit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
.00
3a Fiduciaries – Fill in the amount of credit allocated to beneficiaries . . . . . . . . . . . . 3a
.00
.00
3b Fiduciaries – Subtract line 3a from line 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3b
4
Carryover of unused electronic medical records credit . . . . . . . . . . . . . . . . . . . . . 4
.00
Add lines 3 and 4 (lines 3b and 4 if fiduciary). This is the available electronic
5
medical records credit (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
.00
IC-072