8941 Credit for Small Employer Health Insurance Premiums

Form

8941

Credit for Small Employer Health Insurance Premiums
▶ See

separate instructions.
▶ Attach to your tax return.

Department of the Treasury
Internal Revenue Service

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Identifying number

Enter the number of individuals you employed during the tax year who are considered
employees for purposes of this credit (see instructions) . . . . . . . . . . . . . .
Enter the number of full-time equivalent employees you had for the tax year (see instructions). If
you entered 25 or more, skip lines 3 through 11 and enter -0- on line 12 . . . . . . . .
Average annual wages you paid for the tax year (see instructions). If you entered $50,000 or
more, skip lines 4 through 11 and enter -0- on line 12 . . . . . . . . . . . . . .
Premiums you paid during the tax year for employees included on line 1 for health insurance
coverage under a qualifying arrangement (see instructions) . . . . . . . . . . . .

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Premiums you would have entered on line 4 if the total premium for each employee equaled the
average premium for the small group market in which you offered health insurance coverage
(see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . .

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Enter the smaller of line 4 or line 5

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Multiply line 6 by the applicable percentage:
• Tax-exempt small employers, multiply line 6 by 25% (.25)
• All other small employers, multiply line 6 by 35% (.35) . . . . . . . . . . . . .
If line 2 is 10 or less, enter the amount from line 7. Otherwise, see instructions . . . . . .
If line 3 is $25,000 or less, enter the amount from line 8. Otherwise, see instructions . . . .
Enter the total amount of any state premium subsidies paid and any state tax credits available to
you for premiums included on line 4 (see instructions) . . . . . . . . . . . . . .
Subtract line 10 from line 4. If zero or less, enter -0- . . . . . . . . . . . . . . .
Enter the smaller of line 9 or line 11 . . . . . . . . . . . . . . . . . . . .

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2010
Attachment
Sequence No. 63

Name(s) shown on return

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OMB No. 1545-2198

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If line 12 is zero, skip lines 13 and 14 and go to line 15. Otherwise, enter the number of
employees included on line 1 for whom you paid premiums during the tax year for health
insurance coverage under a qualifying arrangement (see instructions) . . . . . . . . .
Enter the number of full-time equivalent employees you would have entered on line 2 if you only
included employees included on line 13 . . . . . . . . . . . . . . . . . . .
Credit for small employer health insurance premiums from partnerships, S corporations,
cooperatives, estates, and trusts (see instructions) . . . . . . . . . . . . . . .
Add lines 12 and 15. Partnerships and S corporations, stop here and report this amount on
Schedule K; all others, go to line 17 . . . . . . . . . . . . . . . . . . . .
Credit for small employer health insurance premiums included on line 16 from passive activities
(see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . .
Subtract line 17 from line 16 . . . . . . . . . . . . . . . . . . . . . . .
Credit for small employer health insurance premiums allowed for 2010 from a passive activity
(see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . .
Carryback of the credit for small employer health insurance premiums from 2011 . . . . .
Add lines 18 through 20. Cooperatives, estates, and trusts, go to line 22. Tax-exempt small
employers, skip lines 22 and 23 and go to line 24. All others, stop here and report this amount
on Form 3800, line 29h . . . . . . . . . . . . . . . . . . . . . . . .
Amount allocated to patrons of the cooperative or beneficiaries of the estate or trust (see
instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Cooperatives, estates, and trusts, subtract line 22 from line 21. Stop here and report this amount
on Form 3800, line 29h . . . . . . . . . . . . . . . . . . . . . . . .
Enter the amount you paid in 2010 for taxes considered payroll taxes for purposes of this credit
(see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . .
Tax-exempt small employers, enter the smaller of line 21 or line 24 here and on Form 990-T,
line 44f . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

For Paperwork Reduction Act Notice, see separate instructions.

Cat. No. 37757S

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Form 8941 (2010)