Qualifying Wages. Premiums Paid by Employer $ $ $ $ $ $ $ $ $ $ $ $ $ line 5 The smaller of these #'s goes to Form 8941, line 6

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1 Calculation for Small Employer Health Coverage Credit 6/31/211 Input Formula Parish Name Employer State WI enter "" Annual Avg Limit on Premiums MN enter "1" Employer Pd. Percentage of Premium for Full & PartTime Employees Employer Pd. Percentage of Premium for Clergypersons Total number of employees 8941, line 1 Total number of employees employer is paying premiums for Note: These two percentages MUST be the same for in order to get the credit. If % is different, unable to claim credit. 8941, line 13 Small Group Market Rates State Annual Avg State Avg times Employer Pd Percentage Single Coverage $ 5,222 $ Family Coverage $ 12,819 $ Note: Include all employees during the year, whether employment terminated during the year and/or not covered under health care plan. Max number of payroll hours is 2,8. Employee Name Payroll Hours Hours (=<2,8) FICA Wages Wages Premiums Paid by Employer Average Annual Premium "Single" or "Family" Coverage Premiums Full & Parttime Employees $ $ $ $ $ $ $ $ $ $ $ $ $ Clergypersons (Note: Clergypersons should have a number for the payroll hours and $ for FICA wages.) $ $ $ $ $ $ Total Wages n/a $ $ $ $ n/a $ 8941, line , line 5 The smaller of these #'s goes to Form 8941, line 6

2 STEP 3 STEP 1 Payroll Hours Premiums $ Should agree to Form 8941, line 6 Divided by 2,8. Multiplied by Credit Rate (35% Taxable Emp/25% Tax Exempt Emp) 25%. Maximum Credit Available $ 8941, line 7 FTEE Count (Must be less than 25). 8941, line 2 Annual FTEE Phase Out Adjustment Percentage % Annual FTEE Phase Out Amount $ STEP 2 FICA Wages $ Divided by FTE Count Credit after FTEE Phase Out $ 8941, line 8 #DIV/! Annual Wage Phase Out Adjustment Percentage #DIV/! Avg Wages (Must be less than $5,) #DIV/! 8941, line 3 Annual Wage Phase Put Amount #DIV/! If above FTEE count is under 1 and Average Wages Total Allowable Credit Credit after FTEE & Annual Wage Phase Out #DIV/! 8941, line 9 are under $25,, then eligible for the full tax credit of 25%. If not, then watch the phase out's calcuated in Step 3. Tax credit is a refundable credit which means it is limited to certain payroll tax obligations. Total of: Employee's Federal Income Tax Withholdings Employee's Medicare Tax Withholdings Employer's share of Medicare Tax $ 8941, line 24 For Form 8941, line 14 you need the number of FTEE you would have entered on line 2 if you only included employees whom you paid premiums for. Recalculate the above FTEE count by deleting the Limit of tax credit payroll hours of those employees whom you did not pay premiums for. Put the recalculated number of FTEE's on Form 8941, line 14. Amount of credit is lesser of "Allowable Credit" or "Limit" #DIV/! Should agree to Form 8941, line 25 Hit the back button so that the employees payroll hours you deleted are now back in the spreadsheet.

3 Input Formula Parish Name Calculation for Small Employer Health Coverage Credit 6/31/211 EXAMPLE 1 Employer State WI enter "" Annual Avg Limit on Premiums State Avg times Employer Pd MN enter "1" Small Group Market Rates State Annual Avg Percentage Employer Pd. Percentage of Premium for Full & PartTime Employees 75% Note: These two percentages MUST be the Single Coverage $ 5,222 $ 3,917 Employer Pd. Percentage of Premium for same for in order to get the credit. If Clergypersons 75% % is different, unable to claim credit. Family Coverage $ 12,819 $ 9,614 Total number of employees , line 1 Total number of employees employer is paying premiums for , line 13 Note: Include all employees during the year, whether employment terminated during the year and/or not covered under health care plan. Max number of payroll hours is 2,8. Hours Premiums Paid by (<2,8) Wages Employer Average Annual Premium "Single" or "Family" Coverage Premiums Employee Name Payroll Hours FICA Wages Full & Parttime Employees Jackie 2,. 2,. $ 35, $ 35, $ 3,75. $ 3,917 Single 3,75 George 2,. 2,. 25, 25, 3,75. $ 3,917 Single 3,75 Larry 1,5. 1,5. 12,5 12,5 $ Abby 1,5. 1,5. 12,5 12,5 $ $ $ $ $ $ $ $ $ Clergypersons (Note: Clergypersons should have a number for the payroll hours and $ for FICA wages.) Joseph 2,. 2,. 3,75. $ 3,917 Single 3,75 $ $ $ $ $ Seasonal Employees Total Wages n/a 9,. 9,. $ 85, $ 85, $ 11,25 $ 11,75 n/a $ 11, , line , line 5 The smaller of these #'s goes to Form 8941, line 6

4 STEP 3 STEP 1 Payroll Hours 9,. Premiums $ 11,25 Should agree to Form 8941, line 6 Divided by 2,8. Multiplied by Credit Rate (35% Taxable Emp/25% Tax Exempt Emp) 25% 4.33 Maximum Credit Available $ 2, , line 7 FTEE Count (Must be less than 25) , line 2 Annual FTEE Phase Out Adjustment Percentage % Annual FTEE Phase Out Amount $ STEP 2 FICA Wages $ 85, Divided by FTE Count 4 Credit after FTEE Phase Out $ 2, , line 8 $ 21,25 Avg Wages (Must be less than $5,) $ 21, Annual Wage Phase Out Adjustment Percentage % 8941, line 3 Annual Wage Phase Put Amount $ If above FTEE count is under 1 and Average Wages Total Allowable Credit Credit after FTEE & Annual Wage Phase Out $ 2, , line 9 are under $25,, then eligible for the full tax credit of 25%. If not, then watch the phase out's calcuated in Step 3. Tax credit is a refundable credit which means it is limited to certain payroll tax obligations. Total of: Employee's Federal Income Tax Withholdings 1,. For Form 8941, line 14 you need the number of FTEE you would have Employee's Medicare Tax Withholdings 1,232.5 entered on line 2 if you only included employees whom you paid Employer's share of Medicare Tax 1,232.5 premiums for. Recalculate the above FTEE count by deleting the Limit of tax credit $ 3, , line 24 payroll hours of those employees whom you did not pay premiums for. Put the recalculated number of FTEE's on Form 8941, line 14. Amount of credit is lesser of "Allowable Credit" or "Limit" $ 2,812.5 Should agree to Form 8941, line 25 Hit the back button so that the employees payroll hours you deleted are now back in the spreadsheet.

5 Input Formula Parish Name Calculation for Small Employer Health Coverage Credit 6/31/211 EXAMPLE 2 State Avg times Employer State WI enter "" Annual Avg Limit on Premiums Employer Pd MN enter "1" Small Group Market Rates State Annual Avg Percentage Employer Pd. Percentage of Premium for Full & PartTime Employees 75% Note: These two percentages MUST be the Single Coverage $ 5,222 $ 3,917 Employer Pd. Percentage of Premium for same for in order to get the credit. If Clergypersons 75% % is different, unable to claim credit. Family Coverage $ 12,819 $ 9,614 Total number of employees , line 1 Total number of employees employer is paying premiums for , line 13 Note: Include all employees during the year, whether employment terminated during the year and/or not covered under health care plan. Max number of payroll hours is 2,8. Hours Premiums Paid by (<2,8) Wages Employer Average Annual Premium "Single" or "Family" Coverage Premiums Employee Name Payroll Hours FICA Wages Full & Parttime Employees Jackie 2,. 2,. $ 35, $ 35, $ 4,. $ 3,917 Single 3,917 George 2,. 2,. 25, 25, 4,. $ 3,917 Single 3,917 Larry 1,5. 1,5. 12,5 12,5 $ Abby 1,5. 1,5. 12,5 12,5 $ $ $ $ $ $ $ $ $ Clergypersons (Note: Clergypersons should have a number for the payroll hours and $ for FICA wages.) Joseph 2,. 2,. 4,. $ 3,917 Single 3,917 $ $ $ $ $ Seasonal Employees Total Wages n/a 9,. 9,. $ 85, $ 85, $ 12, $ 11,75 n/a $ 11, , line , line 5 The smaller of these #'s goes to Form 8941, line 6

6 STEP 3 STEP 1 Payroll Hours 9,. Premiums $ 11,75 Should agree to Form 8941, line 6 Divided by 2,8. Multiplied by Credit Rate (35% Taxable Emp/25% Tax Exempt Emp) 25% 4.33 Maximum Credit Available $ 2, , line 7 FTEE Count (Must be less than 25) , line 2 Annual FTEE Phase Out Adjustment Percentage % Annual FTEE Phase Out Amount $ STEP 2 FICA Wages $ 85, Divided by FTE Count 4 Credit after FTEE Phase Out $ 2, , line 8 $ 21,25 Avg Wages (Must be less than $5,) $ 21, Annual Wage Phase Out Adjustment Percentage % 8941, line 3 Annual Wage Phase Put Amount $ If above FTEE count is under 1 and Average Wages Total Allowable Credit Credit after FTEE & Annual Wage Phase Out $ 2, , line 9 are under $25,, then eligible for the full tax credit of 25%. If not, then watch the phase out's calcuated in Step 3. Tax credit is a refundable credit which means it is limited to certain payroll tax obligations. Total of: Employee's Federal Income Tax Withholdings 1,. For Form 8941, line 14 you need the number of FTEE you would have Employee's Medicare Tax Withholdings 1,232.5 entered on line 2 if you only included employees whom you paid Employer's share of Medicare Tax 1,232.5 premiums for. Recalculate the above FTEE count by deleting the Limit of tax credit $ 3, , line 24 payroll hours of those employees whom you did not pay premiums for. Put the recalculated number of FTEE's on Form 8941, line 14. Amount of credit is lesser of "Allowable Credit" or "Limit" $ 2, Should agree to Form 8941, line 25 Hit the back button so that the employees payroll hours you deleted are now back in the spreadsheet.

7 Input Formula Parish Name Calculation for Small Employer Health Coverage Credit 6/31/211 EXAMPLE 3 State Avg times Employer State WI enter "" Annual Avg Limit on Premiums Employer Pd MN enter "1" Small Group Market Rates State Annual Avg Percentage Employer Pd. Percentage of Premium for Full & PartTime Employees 75% Note: These two percentages MUST be the Single Coverage $ 5,222 $ 3,917 Employer Pd. Percentage of Premium for same for in order to get the credit. If Clergypersons 75% % is different, unable to claim credit. Family Coverage $ 12,819 $ 9,614 Total number of employees , line 1 Total number of employees employer is paying premiums for , line 13 Note: Include all employees during the year, whether employment terminated during the year and/or not covered under health care plan. Max number of payroll hours is 2,8. Hours Premiums Paid by (<2,8) Wages Employer Average Annual Premium "Single" or "Family" Coverage Premiums Employee Name Payroll Hours FICA Wages Full & Parttime Employees Jackie 2,8. 2,8. $ 3, $ 3, $ 3,75. $ 3,917 Single 375 George 2,8. 2,8. 3, 3, 3,75. $ 3,917 Single 375 Larry 2,8. 2,8. 3, 3, 3,75. $ 3,917 Single 375 Abby 2,8. 2,8. 3, 3, 3,75. $ 3,917 Single 375 Amy 2,8. 2,8. 3, 3, 3,75. $ 3,917 Single 375 Jenny 2,8. 2,8. 3, 3, 3,75. $ 3,917 Single 375 Jack 2,8. 2,8. 3, 3, 3,75. $ 3,917 Single 375 John 2,8. 2,8. 3, 3, 3,75. $ 3,917 Single 375 Jim 2,8. 2,8. 3, 3, 3,75. $ 3,917 Single 375 Sandy 2,8. 2,8. 3, 3, $ Erica 1,4. 1,4. 15, 15, $ Sam 1,4. 1,4. 15, 15, $ Clergypersons (Note: Clergypersons should have a number for the payroll hours and $ for FICA wages.) Joseph 2,8. 2,8. 3,75. $ 3,917 Single 375 $ $ $ $ $ Seasonal Employees Total Wages n/a 24,96. 24,96. $ 33, $ 33, $ 37,5 $ 39,165 n/a $ 37,5 8941, line , line 5 The smaller of these #'s goes to Form 8941, line 6

8 STEP 3 STEP 1 Payroll Hours 24,96. Premiums $ 37,5 Should agree to Form 8941, line 6 Divided by 2,8. Multiplied by Credit Rate (35% Taxable Emp/25% Tax Exempt Emp) 25% 12. Maximum Credit Available $ 9, , line 7 FTEE Count (Must be less than 25) , line 2 Annual FTEE Phase Out Adjustment Percentage 13% Annual FTEE Phase Out Amount $ (1,25) STEP 2 FICA Wages $ 33, Divided by FTE Count 12 Credit after FTEE Phase Out $ 8, , line 8 $ 27,5 Avg Wages (Must be less than $5,) $ 27, Annual Wage Phase Out Adjustment Percentage 8% 8941, line 3 Annual Wage Phase Put Amount $ (75) If above FTEE count is under 1 and Average Wages Total Allowable Credit Credit after FTEE & Annual Wage Phase Out $ 7, , line 9 are under $25,, then eligible for the full tax credit of 25%. If not, then watch the phase out's calcuated in Step 3. Tax credit is a refundable credit which means it is limited to certain payroll tax obligations. Total of: Employee's Federal Income Tax Withholdings 1,4. For Form 8941, line 14 you need the number of FTEE you would have Employee's Medicare Tax Withholdings 2,3. entered on line 2 if you only included employees whom you paid Employer's share of Medicare Tax 2,3. premiums for. Recalculate the above FTEE count by deleting the Limit of tax credit $ 6,. 8941, line 24 payroll hours of those employees whom you did not pay premiums for. Put the recalculated number of FTEE's on Form 8941, line 14. Amount of credit is lesser of "Allowable Credit" or "Limit" $ 6,. Should agree to Form 8941, line 25 Hit the back button so that the employees payroll hours you deleted are now back in the spreadsheet.