Required Fields

Out-of-pocket cost for health insurance - Dollar amount

Enter the total amount that you paid for your eligible employees' insurance. Do not include any amount paid by state state subsidies and / or tax credits.

State subsidies and / or tax credits - Dollar amount

If you received them, enter the total amount here. If you did not receive any, enter 0 (zero).

Full-time employees - Number

Enter the number of full time employees that worked for you for the year. Full-time employees are those who worked 2,080 or more hours for you.

Part time and other employees - Number

For all your employees that are not full time, enter the total hours all of them worked for you. This number is divided by 2,080 and added to the full time employees to arrive at your FTEs.

Total wages paid - Dollar amount

Enter the total wages you paid to all your employees for the year. This is divided by the FTEs to arrive at your average annual wages.

Eligible tax-exempt employer - Yes / No

If you are an eligible tax-exempt employer, click “yes." Additional fields will show for:

• Income tax withheld from employees,
• Medicare tax withheld from employees, and
• Your share of Medicare tax.

Each of these fields is monetary. The credit for tax-exempt employers is limited to the sum of these three fields.

State(s) where you have employees - Yes / No and Drop-Down List

If no, select your state from the drop-down list.

If yes, you will select each of your states from multiple lists. For each selection, another drop-down list will appear. You need to select at least one state.