Arizona Form 347 - Credit For Qualified Health Insurance Plans - 2012 Page 3
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3Your Name (as shown on Form 347, page 1)
Your Social Security or Employer Identification Number
Form 347-1 (2012)
Qualified Employees for Which You Are Claiming a Credit
(To qualify, the amount in column (c) must be at least $360 for each employee listed.)
(a)
(b)
(c)
Employer’s Amount of Expenses for:
Name of Qualified Employee
Social Security
• Employee’s Qualified Health Insurance Plan, and
(must be an Arizona resident)
Number
• Employee’s Health Savings Account
.00
1
.00
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.00
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.00
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.00
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.00
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.00
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.00
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.00
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.00
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.00
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.00
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.00
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.00
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21 Number of Qualified Employees:
Enter the total number of qualified employees here and on page 1, line 4. If more
than 20 employees, enter the total from all schedules ........................................... 21
If you have more than 20 qualifying employees, complete additional schedules.
ADOR 11177 (12)
Print 347-1
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Parent category: Financial