Form CrDepHealthBenCr Fillable Credit for Dependent Health Benefits Paid
(all forms fillable on Windows, Mac, Android tablets, and iPad using Adobe Reader XI)

(see definition of dependent health benefits in the instructions) 3 36 M R S 5219 O 60% of the cost of dependent health insurance benefits for children under 19 who are dependents of low income a complete definition of employer see 26 M R S 1043 A taxpayer that employs five or more employees after qualifying for the credit may continue to qualify for the Amount paid for dependent health benefits in 2015 with respect to low income employees and x ray services; and well baby and well child care including age appropriate immunizations The plan must at least 80% of the health insurance costs for each low income employee under the plan; and 3) pays at least be carried forward for two years benefit of the employees dependents Carryforward from previous years 6 Credit amount: Enter the lesser of line 7 or line 9 (enter here and on Form 1120ME Credit claimed Enter the lesser of line 2 or line 4 5 credit for another two years Otherwise a taxpayer may claim a credit only for those periods during which the Dependent health benefits means health benefits and health insurance costs allowable as deductions to the Dependent means a dependent as defined by IRC 152 who is under 19 years of age EIN/SSN employee that do not exceed 10% of the actuarial value of all benefits afforded by the plan and makes the same employees under the plan The credit is limited to 50% of the regular income tax due Any unused credit may Employer means an entity that employs one or more individuals performing services for it within this state For employer under IRC 105 paid by the taxpayer on behalf of the taxpayer s low income employees for the employer: 1) offers a qualified health benefit plan that is made available to all low income employees; 2) pays exceed the state s average weekly wage as calculated by the Department of Labor fewer than five employees This credit is equal to the lesser of 20% of the dependent health benefits paid by In the case of pass through entities (such as partnerships LLCs S corporations and trusts) the partners income employees See definition of dependent health benefi ts above interest in these entities investment see instructions Enter name and ID number of the entity on the lines below Line 1 x $125 2 Line 3 Enter the total amount paid by the employer to provide dependent health benefits in 2015 for low Line 3 x 20% (0 20) 4 Line 6 Enter any tax credit amounts claimed in 2013 or 2014 but not used Line 8 x 50% (0 50) 9 Lines 8 & 9 The credit is limited to 50% of the Maine tax liability Low income employee means a Maine resident whose average weekly earnings from the employer do not members shareholders beneficiaries or other owners are allowed a credit in proportion to their respective must be based on the same assumptions The plan must also impose copayment and deductible costs on the NAME OF PASS THROUGH ENTITY Note: Number of low income employees in 2015 with dependent health benefi ts coverage 1 of a benefit based on assumptions as to relevant variables such as morbidity mortality persistency and interest of age or comparable coverage available for the benefit of the employee s dependent children who are under 19 years or Form 1040ME Schedule A line 22 or Form 1041ME Schedule A line 18) 8 Owners of pass through entities (such as partnerships LLCs S corporations and trusts) making an eligible period may be claimed on your Maine income tax return next year Please enter the employer name and social security number ( SSN ) or employer identification number ( EIN ) provide coverage that has an actuarial value no less than 80% of the actuarial value of coverage that is provided Qualified health benefi t plan means a plan that includes comprehensive coverage for at least the following range of benefits: inpatient and outpatient hospital services; physicians surgical and medical services; laboratory Rev 08/15 Schedule A line 16) 10 Schedule C line 29k or Form 1040ME Schedule A line 20 or Form 1041ME SPECIFIC LINE INSTRUCTIONS TAX CREDIT FOR DEPENDENT HEALTH BENEFITS PAID Tax liability (Form 1120ME line 7a plus any credit recapture amounts included in line 7b TAXPAYER NAME: EIN/SSN: That portion of the unused credit not exceeding the 2 year carryover the employer for low income employees or $125 per low income employee with dependent health coverage This credit is available to employers that offer a qualified health benefit plan (defined below) and that employ to employees of the State of Maine For purposes of this paragraph actuarial value means the expected cost Total credit available this year: Line 5 plus line 6 7 When comparing the actuarial value of one benefit or package of benefits to another both actuarial values WORKSHEET FOR TAX YEAR 2015 WORKSHEET INSTRUCTIONS