Employer-Provided Long-Term Care Benefits Tax Credit Worksheet For Tax Year 2015

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EMPLOYER-PROVIDED LONG-TERM CARE BENEFITS
TAX CREDIT WORKSHEET FOR TAX YEAR 2015
36 M.R.S. § 5217-C
TAXPAYER NAME: _____________________________________ EIN/SSN: ________________
Note: Owners of pass-through entities (such as partnerships, LLCs, S corporations, and trusts) making an eligible
investment, see instructions. Enter name and ID number of the entity on the lines below.
NAME OF PASS-THROUGH ENTITY
EIN/SSN
________________________________________________________________
____________________________
1.
Number of employees with eligible long-term care insurance coverage provided
by the employer during the tax year ........................................................................................1. __________________
2.
Line 1 x $100 ..........................................................................................................................2. __________________
3.
Costs incurred in providing eligible long-term care insurance
coverage for employees during the taxable year ....................................................................3. __________________
4.
Line 3 x 20% (0.20) .................................................................................................................4. __________________
5.
Credit claimed. Enter the lowest of line 2, line 4 or $5,000 ....................................................5. __________________
6.
Credit carried forward from previous tax years (see instructions) ...........................................6. __________________
7.
Total credit available this year (line 5 plus line 6). Corporate taxpayers, enter on
Form 1120ME, Schedule C, line 29d. Individual taxpayers, enter on Form 1040ME,
Schedule A, line 20. Trusts and estates, enter on Form 1041ME, Schedule A, line 16 .........7. __________________
The credit is limited to the tax liability, excluding minimum tax, of the taxpayer. Any
unused credit may be carried forward for up to 15 years.
Rev. 08/15

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