Form It-249 - Claim For Long-Term Care Insurance Credit - 2012
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1
2New York State Department of Taxation and Finance
IT-249
Claim for Long-Term Care
Insurance Credit
Tax Law - Section 606(aa)
Name(s) as shown on return
Identifying number as shown on return
Submit this form with Form IT-201, IT-203, IT-204, or IT-205.
Schedule A – Individuals (including sole proprietors), partnerships, and fiduciaries
1 Qualified long-term care insurance premiums paid for the current tax year................................
.
1
00
.
2 Credit rate (20%) .........................................................................................................................
2
20
3 Credit for qualified long-term care insurance
.
...........................................
3
(multiply line 1 by line 2)
00
Fiduciaries: Include the amount from line 3 in the Total line of Schedule D, column C.
All others: Enter the amount from line 3 on Schedule E, line 8.
Schedule B – Partnership, S corporation, estate, and trust information
(see instructions)
If you were a partner in a partnership, a shareholder of a New York S corporation, or a beneficiary of an estate or trust and received a share of the
long-term care insurance credit from that entity, complete the following information for each partnership, New York S corporation, estate, or trust.
For Type, enter P for partnership, S for S corporation, or ET for estate or trust.
Name of entity
Type
Employer ID number
Schedule C – Partner’s, shareholder’s, or beneficiary’s share of credit
Partner
.
4 Enter your share of the credit from your partnership
..............
(see instructions)
4
00
S corporation
shareholder
5 Enter your share of the credit from your S corporation
...........
.
(see instructions)
5
00
6 Enter your share of the credit from the fiduciary’s Form IT-249, Schedule D,
Beneficiary
.
column C .........................................................................................................
6
00
7 Totals
...............................................................................
.
(add lines 4, 5, and 6)
7
00
Fiduciaries: Include the amount from line 7 in the Total line of Schedule D, column C.
All others: Enter the amount from line 7 on Schedule E, line 9.
Schedule D – Beneficiary’s and fiduciary’s share of credit
A
B
C
Beneficiary’s name
Share of qualified long-term
Identifying number
(same as on
care insurance credit
Form IT-205, Schedule C)
Total
(enter the amount from Schedule A, line 3, plus the
amount from Schedule C, line 7)
.
00
.
00
.
00
Fiduciary
.
00
(continued on back)
249001120094
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