- 1 -
|
State of Rhode Island Division of Taxation
2023 Shared Responsibility Worksheet
Individual Health Insurance Mandate Penalty Calculation IMAGEONLY
Name Social security number
NOTE: Use this worksheet to determine the amount of your Shared Responsibility Penalty Amount
Attach this Worksheet along with Form IND-HEALTH to your personal income tax return
INDIVIDUAL HEALTH INSURANCE MANDATE PENALTY CALCULATION FOR RHODE ISLAND for TY2023
STEP 1: FLAT DOLLAR AMOUNT METHOD
1 Enter the number of months that members of the tax household DID NOT HAVE coverage or an exemption
a Total number of months for ALL ADULTS: X $57.92 Enter total here -> 1b
c Total number of months for 1d
ALL CHILDREN UNDER 18 YEARS OF AGE: X $28.96 Enter total here ->
2 Add the amounts from lines 1b and 1d........................................................................................................... 2
3 Enter the amount from line 2 or the amount from the Flat Fee Method Worksheet on page IND-8, 3
whichever is less............................................................................................................................................
STEP 2: PERCENTAGE OF INCOME METHOD
4 Enter your Modified Adjusted Gross income (see instructions)...................................................................... 4
5 Enter your Federal Standard Deduction (see instructions)............................................................................ 5
6 Subtract the amount on line 5 from the amount on line 4............................................................................... 6
7 Income Percentage Amount. Multiply the amount on line 6 by 2.5% (0.025)................................................ 7
8 Enter the total number of members in your household. 8
NOTE: All members should be listed on Form IND-HEALTH - Individual Health Insurance Mandate Form.
9 Multiply the number of household members from line 8 by 12.0.................................................................... 9
10 Total number of months subject to the penalty. Add lines 1a and 1c............................................................. 10
11 Divide line 10 by line 9. Carry apportionment to four decimal places (0.0000)............................................. 11
_ . _ _ _ _
12 Multiply line 11 by line 7................................................................................................................................................ 12
13 Enter the amount from line 3 or line 12, whichever is greater........................................................................ 13
STEP 3: BRONZE PLAN METHOD
14 a Enter the number of months subject to the penalty from line 10.................................................................... 14a
b Multiply the number of months from line 14a X $350 and enter the total here................................................... 14b
c Enter the amount listed to the 1 member: $4,200 2 members: $8,400 3 members: $12,600 14c
right for your tax household size 4 members: $16,800 5 or more members: $21,000
d Enter the amount from line 14b or line 14c, whichever is less....................................................................... 14d
15 Individual Mandate Penalty. Enter the amount from line 13 or line 14d, whichever is less. Enter this 15
amount on Form RI-1040, page 1, line 12b or Form RI-1040NR, page 1, line 15b.......................................
|