OMB No. 1545-2198
                             Credit for Small Employer Health Insurance Premiums
Form 8941
                                                       Attach to your tax return.                                                   23
                                                                                                                            20
Department of the Treasury       Go to www.irs.gov/Form8941 for instructions and the latest information.                    Attachment   
Internal Revenue Service                                                                                                    Sequence No. 65
Name(s) shown on return                                                                                           Identifying number

A    Did you pay premiums during your tax year for employee health insurance coverage you provided                through a Small Business 
     Health Options Program (SHOP) Marketplace (or do you qualify for an exception to this requirement)? See instructions.
        Yes. Enter Marketplace Identifier (if any):
        No. Stop. Do not file Form 8941. See instructions for an exception that may apply to a partnership, S corporation, cooperative, 
     estate, trust, or tax-exempt entity.
B    Enter  the  employer  identification  number  (EIN)  used  to  report  employment  taxes  for  individuals  included  on  line  1  below  if
     different from the identifying number listed above: 
C    Does a tax return you (or any predecessor) filed for a tax year beginning after 2013 and before 2022 include a Form 8941 with
     line A checked “Yes” and line 12 showing a positive amount? See instructions.
        Yes. Stop. Do not file Form 8941. See instructions for an exception that may apply to a partnership, S corporation, cooperative, 
        estate, trust, or tax-exempt entity. Also see instructions for information about the credit period limitation.
        No. Go to line 1.
Caution: See the instructions and complete Worksheets 1 through 7 as needed.
1    Enter the number of individuals you employed during the tax year who are considered employees 
     for purposes of this credit (total from Worksheet 1, column (a))  . .  .     . . . . . .       . .           1
2    Enter  the  number  of  full-time  equivalent  employees  (FTEs)  you  had  for  the  tax  year  (from
     Worksheet 2, line 3). 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 (from Worksheet 3, line 3). This amount must be a 
     multiple of $1,000. If you entered $62,000 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 (total from Worksheet 4, column (b))  .    . . .       . .           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 the employee enrolls in health insurance
     coverage (total from Worksheet 4, column (c))  .  . .       . . . . .  .     . . . . . .       . .           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 35% (0.35)
     • All other small employers, multiply line 6 by 50% (0.50)  .   . . .  .     . . . . . .       . .           7
8    If line 2 is 10 or less, enter the amount from line 7. Otherwise, enter the amount from Worksheet 
     5, line 6 .         . . . . . . .  .  .   . . .   . .       . . . . .  .     . . . . . .       . .           8
9    If  line  3  is  $30,000  or  less,  enter  the  amount  from  line  8.  Otherwise,  enter  the  amount  from
     Worksheet 6, line 7       . . . .  .  .   . . .   . .       . . . . .  .     . . . . . .       . .           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 (total from Worksheet 4, column (a))  . .     . . . . . .       . .           13
14   Enter  the  number  of  FTEs  you  would  have  entered  on  line  2  if  you  only  included  employees 
     included on line 13 (from Worksheet 7, line 3)  . . .       . . . . .  .     . . . . . .       . .           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. Cooperatives, estates, and trusts, go to line 17. Tax-exempt small employers, 
     skip lines 17 and 18 and go to line 19. Partnerships and S corporations, stop here and report this 
     amount on Schedule K. All others, stop here and report this amount on Form 3800, Part III, line 4h           16
17   Amount allocated to patrons of the cooperative or beneficiaries of the estate or trust (see instructions)    17
18   Cooperatives, estates, and trusts, subtract line 17 from line 16. Stop here and report this amount 
     on Form 3800, Part III, line 4h  . .  .   . . .   . .       . . . . .  .     . . . . . .       . .           18
19   Enter the amount you paid in 2023 for taxes considered payroll taxes for purposes of this credit. 
     See instructions .      . . . . .  .  .   . . .   . .       . . . . .  .     . . . . . .       . .           19
20   Tax-exempt small employers, enter the     smaller of line 16 or line 19 here and on Form 990-T, 
     Part III, line 6f     . . . . . .  .  .   . . .   . .       . . . . .  .     . . . . . .       . .           20
For Paperwork Reduction Act Notice, see separate instructions.                      Cat. No. 37757S                         Form 8941 (2023)