Form 8941

Department of the Treasury 

Internal Revenue Service

Credit for Small Employer Health Insurance Premiums

▶ See separate instructions.

▶ Attach to your tax return.

OMB No. 1545-2198

2010

Attachment 

Sequence No. 63

Name(s) shown on return Identifying number

1 Enter the number of individuals you employed during the tax year who are considered

employees for purposes of this credit (see instructions) . . . . . . . . . . . . . . 1

2 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 . . . . . . . . 2

3 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 . . . . . . . . . . . . . . 3

4 Premiums you paid during the tax year for employees included on line 1 for health insurance

coverage under a qualifying arrangement (see instructions) . . . . . . . . . . . . 4

5 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) . . . . . . . . . . . . . . . . . . . . . . . . . . 5

6 Enter the smaller of line 4 or line 5 . . . . . . . . . . . . . . . . . . . . 6

7 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) . . . . . . . . . . . . . 7

8 If line 2 is 10 or less, enter the amount from line 7. Otherwise, see instructions . . . . . . 8

9 If line 3 is $25,000 or less, enter the amount from line 8. Otherwise, see instructions . . . . 9

10 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) . . . . . . . . . . . . . . 10

11 Subtract line 10 from line 4. If zero or less, enter -0- . . . . . . . . . . . . . . . 11

12 Enter the smaller of line 9 or line 11 . . . . . . . . . . . . . . . . . . . . 12

13 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) . . . . . . . . . 13

14 Enter the number of full-time equivalent employees you would have entered on line 2 if you only

included employees included on line 13 . . . . . . . . . . . . . . . . . . . 14

15 Credit for small employer health insurance premiums from partnerships, S corporations, 

cooperatives, estates, and trusts (see instructions) . . . . . . . . . . . . . . . 15

16 Add lines 12 and 15. Partnerships and S corporations, stop here and report this amount on

Schedule K; all others, go to line 17 . . . . . . . . . . . . . . . . . . . . 16

17 Credit for small employer health insurance premiums included on line 16 from passive activities 

(see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . 17

18 Subtract line 17 from line 16 . . . . . . . . . . . . . . . . . . . . . . . 18

19 Credit for small employer health insurance premiums allowed for 2010 from a passive activity 

(see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . 19

20 Carryback of the credit for small employer health insurance premiums from 2011 . . . . . 20

21 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 . . . . . . . . . . . . . . . . . . . . . . . . 21

22 Amount allocated to patrons of the cooperative or beneficiaries of the estate or trust (see 

instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

23 Cooperatives, estates, and trusts, subtract line 22 from line 21. Stop here and report this amount 

on Form 3800, line 29h . . . . . . . . . . . . . . . . . . . . . . . . 23

24 Enter the amount you paid in 2010 for taxes considered payroll taxes for purposes of this credit 

(see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . 24

25 Tax-exempt small employers, enter the smaller of line 21 or line 24 here and on Form 990-T, 

line 44f . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

For Paperwork Reduction Act Notice, see separate instructions. Cat. No. 37757S Form 8941 (2010)