Schedule M1LTI, Long-Term Care Insurance Credit 2014
Sequence #17
Your fi rst name and initial
Last name
Social Security number
If you (or your spouse, if fi ling a joint return) paid premiums in 2014 for a qualifi ed long-term care insurance policy, complete this
schedule to determine the amount, if any, you can subtract from your tax when you fi le Form M1.
To qualify for this credit, your long-term care insurance policy must:
• qualify as a federal deduction (see federal Schedule A of Form 1040), disregarding the 7.5 or 10 percent income test, and
• have a lifetime long-term care benefi t limit of $100,000 or more.
There are no separate instructions for Schedule M1LTI.
Policy Information (only one qualifying policy per person):
Name of Insured
Insurance Company
Policy Number
#A
#B
Provide the information in the appropriate column for each insured person. If you
are fi ling a joint return and both you and your spouse are covered by one policy,
Round amounts to the
use half of the premiums in column A and half in column B (below).
nearest whole dollar.
You
Spouse
A
B
1 Premiums paid in 2014 for the qualifying long-term care insurance policy . . . . . . 1
Did you itemize deductions on your federal Form 1040?
• If no, skip lines 2, 3 and 4, and enter line 1 on line 5.
• If yes, continue with line 2.
2 Amount of premiums paid on this policy that are included on
line 1 of federal Schedule A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
3 Amount on line 4 of federal Schedule A
(If you and your spouse are claiming premiums paid,
enter half of this amount in each column.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
4 Amount from line 2 or line 3, whichever is less . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
5 Subtract line 4 from line 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
6 Multiply line 5 by 25% (.25) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
$100
$100
7 The maximum credit is $100 per person . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
8 Amount from line 6 or line 7, whichever is less . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
9 Add line 8, columns A and B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Full-year residents: Also enter this amount on line 1 of Schedule M1C.
Part-year Residents and Nonresidents
10 Multiply line 9 by line 25 of Schedule M1NR.
Enter the result here and on line 1 of Schedule M1C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
You must include this schedule and Schedule M1C with your Form M1.
9995