Maine Credit For Wellness Programs Worksheet For Tax Year 2015

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CREDIT FOR WELLNESS PROGRAMS
WORKSHEET FOR TAX YEAR 2015
36 M.R.S. § 5219-FF
TAXPAYER NAME: _____________________________________ EIN/SSN: ________________
Note: In the case of pass-through entities (such as partnerships, LLCs, S corporations, and trusts) making eligible
expenditures, the partners, members, shareholders, benefi ciaries, or other owners are allowed a credit in proportion
to their respective interests in these entities. Enter name and ID number of the entity on the lines below. Also enter
your ownership percentage in the pass-through entity for the tax year.
NAME OF PASS-THROUGH ENTITY
EIN/SSN
OWNERSHIP
PERCENTAGE
_____________________________________________________
_____________________
____________ %
1.
Number of Employees (on an average monthly basis) ........................................................... 1. __________________
2.
Line 1 x $100.00 ..................................................................................................................... 2. __________________
3.
Total expenditure to develop, institute and maintain a wellness program made during
the taxable year ...................................................................................................................... 3. __________________
4.
Amount of unused credit on 2014 credit worksheet, line 3, carried forward to 2015 .............. 4. __________________
5.
Line 3 plus line 4 ..................................................................................................................... 5. __________________
6.
Enter the amount from line 2, 5, or $2,000, whichever is less. Enter here and on
Form 1040ME, Schedule A, line 14; Form 1041ME, Schedule A, line 10; or Form 1120ME,
Schedule C, line 29m .............................................................................................................. 6. __________________
Unused credit amounts on line 3 may be carried forward for up to fi ve years.
WORKSHEET INSTRUCTIONS
An employer with 20 or fewer employees (calculated on an average monthly basis) may qualify for the credit for wellness
programs. An employer is a taxpayer that employs one or more individuals performing services for the taxpayer within
Maine.
The credit is equal to expenditures made during the taxable year to develop, institute and maintain a wellness program. The
total credit (including the carryover of unused credit amounts from prior years) is limited to the lesser of $100 per employee
or $2,000, and may not reduce tax liability to less than zero. Any unused credit amounts on line 3 may be carried forward
for up to 5 years.
A wellness program is a program that improves employee health, morale and productivity. This includes, but is not limited
to, health education programs, behavioral change programs and incentive awards to employees who engage in regular
physical activity. Behavioral change programs include counseling, seminars or classes on nutrition, stress management,
or smoking cessation.
Rev. 01/16

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