Form Mo-Shc - Self-Employed Health Insurance Tax Credit

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MISSOURI DEPARTMENT OF REVENUE
DLN
FORM
TAXATION DIVISION
MO-SHC
SELF-EMPLOYED HEALTH INSURANCE
TAX CREDIT
(REV. 11-2010)
TAXPAYER INFORMATION
NAME
SOCIAL SECURITY NUMBER
__ __ __ - __ __ - __ __ __ __
SPOUSE’S NAME
SPOUSE’S SOCIAL SECURITY NUMBER
__ __ __ - __ __ - __ __ __ __
QUALIFICATIONS
If you are a self-employed individual and were not able to deduct all of your health care premiums from your federal adjusted gross income, you may be
eligible for a tax credit equal to the portion of your federal tax liability incurred due to the inclusion of your health care premiums in your federal adjusted
gross income. The self-employed health insurance tax credit is refundable.
INSTRUCTIONS
Calculate your tax credit by using either method below and enter the total on Form MO-TC. Self-employed individuals with personal exemptions and/or
itemized deductions limited on their federal return because their federal adjusted gross income exceeded the limits established by the Internal Revenue
Service should use the Regular Method. If you are filing a combined return, and both spouses were self-employed and paid health insurance premiums,
combine the amounts paid by both spouses when calculating your credit. Attach completed MO-SHC, pages 1 and 2 of federal Form 1040, and federal
Schedule C, if applicable, to Form MO-TC.
SHORT METHOD
1. Federal taxable income from federal Form 1040, Line 43 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
00
2. Amount you paid for health insurance premiums which were included in
federal adjusted gross income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
00
0
3. Subtract Line 2 from Line 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
00
4. Calculate an adjusted federal tax by comparing the amount on Line 3 with the federal tax tables . . . . . . . . . . . . . . . . . . 4
00
5. Federal tax from your federal Form 1040, Line 44. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
00
0
6. Subtract Line 4 from Line 5. This is your self-employed health insurance tax credit. Report on Form MO-TC. . . 6
00
REGULAR METHOD
1. Federal adjusted gross income from federal Form 1040, Line 37 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
00
2. The amount you paid for health insurance premiums which were included in your
federal adjusted gross income. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
00
0
3. Subtract Line 2 from Line 1. This is your revised federal adjusted gross income. . . . . . . . . . . . . . . . . . . . . . . . . . 3
00
4. Enter your standard or itemized deductions. If your itemized deductions were reduced because your income
was over the limit, use the amount from Line 3 of this worksheet to recalculate the itemized deductions. . . . . . . 4
00
5. Enter your personal exemption amount. If your personal exemption was reduced because your income was
over the limit, use the amount from Line 3 of this worksheet to recalculate the personal exemption . . . . . . . . . . . 5
00
0
6. Add Lines 4 and 5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
00
0
7. Subtract Line 6 from Line 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
00
8. Calculate an adjusted federal tax by computing the amount on Line 7 with the federal tax tables.
Enter the adjusted amount here . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
00
9. If you paid an alternative minimum tax, use the revised federal adjusted gross income from Line 3 on this
worksheet to recalculate the tax calculated on Form 6251, and enter the revised amount. . . . . . . . . . . . . . . . . . . 9
00
0
10. Add Lines 8 and 9. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
00
11. If you reduced your tax by any of the credits listed on federal Form 1040, Lines 47–53, use the revised federal
adjusted gross income from Line 3 on this worksheet to recalculate each of the credits to which you are eligible,
and enter the total of all the credit amounts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
00
0
12. Subtract Line 11 from Line 10. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
00
13. Total of federal Form 1040, Lines 56-59. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
00
0
14. Add Lines 12 and 13. This is your revised federal tax liability. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
00
15. Amount from federal Form 1040, Line 60. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
00
0
16. Subtract Line 14 from Line 15. This is your self-employed health insurance tax credit. Report on Form MO-TC. . . 16
00
I declare under penalties of perjury that I employ no illegal or unauthorized aliens as defined under federal law and that I am not eligible for any tax exemption, credit or abatement if
I employ such aliens. I also declare that if I am a business entity, I participate in a federal work authorization program with respect to the employees working in connection with any
contracted services, and I do not knowingly employ any person who is an unauthorized alien in connection with any contracted services.
MO-SHC (11-2010)

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