Schedule Em - Electronic Medical Records Credit - 2012
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1
2Electronic Medical Records
EM
Schedule
Credit
2012
Wisconsin Department
Enclose with Form 1, 1NPR, 2, 3, 4, 4T, 5, or 5S
of Revenue
Name
Identifying Number
1
Fill in the amount of electronic medical records credit allocated to you by the
Wisconsin Department of Revenue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
.00
2
Electronic medical records credit passed through from other entities
2a Entity Name
FEIN
2a Amount
.00
2b Entity Name
FEIN
2b Amount
.00
2c Entity Name
FEIN
2c Amount
.00
2d Entity Name
FEIN
2d Amount
.00
.00
2e Total pass through credits from additional schedule . 2e
2f Total credits (add lines 2a through 2e) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2f
.00
3
Add the amounts on lines 1 and 2f. This is your 2012 electronic medical records
credit (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
.00
3a Fiduciaries – Fill in the amount of credit allocated to beneficiaries . . . . . . . . . . . . 3a
.00
.00
3b Fiduciaries – Subtract line 3a from line 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3b
IC-072i (N. 9-12)
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