Schedule K-57 - Kansas Small Employer Healthcare Credit
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2K-57
KANSAS
SMALL EMPLOYER HEALTHCARE CREDIT
(Rev. 9/13)
For the taxable year beginning _________________ , 20____ ; ending _________________ , 20____ .
Name of taxpayer (as shown on return)
Employer ID Number (EIN)
Name of parent corporation
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 (C Corporations only)
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
(a)
(b)
(c)
(d)
(e)
(f)
NEXT 12 MONTHS
Number of eligible
Maximum allowed.
Number of eligible
FIRST 12 MONTHS
NEXT 12 MONTHS
employees for the
Multiply amount in (e)
employees for the
Multiply amount in (a) by
Multiply amount in (a) by
Multiply amount in (a) by
month
by $35.
month
the lesser of $70 or the
the lesser of $50 or the
the lesser of $35 or the
actual amount paid per
actual amount paid per
actual amount paid per
(By Tax Year)
employee.
employee.
employee.
1. 1st month
2. 2nd month
3. 3rd month
4. 4th month
5. 5th month
6. 6th month
7. 7th month
8. 8th month
9. 9th month
10. 10th month
11. 11th month
12. 12th month
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 and
enter result. Enter this amount on the appropriate line of Form K-120.
18. _________________
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