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STATE OF HAWAII—DEPARTMENT OF TAXATION
FORM
TAX YEAR
HEALTHCARE PRECEPTOR
N-358 INCOME TAX CREDIT 20__
(REV. 2023)
Or fiscal year beginning _________________, 20____, and ending __________________, 20____
ATTACH TO FORM N-11 or N-15
Name as shown on Form N-11 or N-15 SSN
Part I CREDIT CERTIFICATE
DEPARTMENT OF HEALTH CERTIFICATE
(Completed by the Department of Health only)
1. Name of taxpayer 2. SSN
3. Address (Number and street, including apartment number or rural route, city, state, and postal/zip code)
4. Total qualified rotations: ...........................................................................................................
5. Amount of tax credit allowed for the taxable year ..................................................................... $
This is to certify that the amounts noted above have been verified in accordance with section 235-110.25, Hawaii Revised Statutes.
Signature of Certifying Officer Date of Certification
Type or Print Name and Title N358_I 2023A 01 VID01
Part II COMPUTATION OF TAX CREDIT
1 Total New Credit Claimed — Enter the tax credit allowed for the taxable year from Part I, line 5. Also enter this
amount on Schedule CR in Column (a) of the appropriate line for this tax credit ........................................................ 1
2 Carryover of unused healthcare preceptor income tax credit from prior year............................................................... 2
3 Tentative current year healthcare preceptor income tax credit — add lines 1 and 2 .................................................... 3
4 Adjusted Tax Liability — enter your adjusted tax liability from Form N-11 or Form N-15 ......................................... 4
5 If you are claiming other nonrefundable tax credits, complete the worksheet on page 2 of the instructions and
enter the total here. If you are not claiming other nonrefundable credits, enter zero ................................................... 5
6 Line 4 minus line 5. This represents your remaining tax liability. If the result is zero or less, enter zero ...................... 6
7 Total Credit Applied — enter the smaller of line 3 or line 6. This is your healthcare preceptor income tax credit
applied for the year. Also, enter this amount on Schedule CR in Column (b) of the appropriate line for this credit. ... 7
8 Unused Credit to Carryover — Line 3 minus line 7. This represents your unused credit available to carryforward
to be used against tax liability in subsequent tax years until exhausted. If this amount is more than zero, also enter
this on Schedule CR in Column (c) of the appropriate line for this tax credit .............................................................. 8
GENERAL INSTRUCTIONS CREDIT REQUIREMENTS be used as a credit against the taxpayer’s income
Section 235-110.25, HRS, provides that the tax liability in subsequent years until exhausted.
PURPOSE OF FORM amount of the credit is: DEADLINE FOR CLAIMING THE CREDIT
Use Form N-358 to figure and claim the health-
(1) Equal to $1,000 for each volunteer-based
care preceptor income tax credit under section The deadline to claim the credit, including
supervised clinical training rotation, up to
235-110.25, Hawaii Revised Statutes (HRS). amended claims, is 12 months after the close of
a maximum of $5,000 per taxable year, your taxable year. You cannot claim or amend the
WHO MAY CLAIM THIS CREDIT regardless of the number of volunteer- credit after the deadline.
For taxable years beginning AFTER December based supervised clinical training rotations
31, 2018, each taxpayer who provides volunteer- supervised by the taxpayer. DEFINITIONS FOR PURPOSES OF THE
based supervised clinical training rotations that To claim this credit, you must complete and at- CREDIT
are certified by the Department of Health may tach to your Hawaii income tax return: “Academic program” means an academic de-
gree granting program or graduate medical edu-
claim a nonrefundable healthcare preceptor in- (1) Form N-358 (Complete Part II and attach.) cation program that:
come tax credit for the taxable year in which the
taxpayer’s qualified rotations are certified by the (2) Schedule CR (1) Holds either its principal accreditation or a
Department of Health. If the credit exceeds the taxpayer’s net income physical location in Hawaii; and
tax liability, the excess of credit over liability may
(2) Provides education to students, of whom more
than fifty percent are residents of Hawaii.
ID NO 01 FORM N-358 (REV. 2023)
