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Vermont Department of Taxes PO Box 547 Montpelier, VT 05601-0547
Phone: (802) 828-2551 Do not return this form to the
Vermont Department of Taxes.
VT Form You must retain this form for your
HEALTH CARE CONTRIBUTIONS WORKSHEET records for three years.
HC-1
Page 3
Employer FEIN Quarter / Year
Uncovered Employee Count:
Did you have 5 or more full-time equivalent (FTE) employees who were all age 18 and
older in the previous quarter? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
• If you answered NO, check this box to certify no Health Care Fund Contributions
will be due for this quarter .
• If you answered YES, complete Section 1 or2 below (not both) depending on the
health care coverage offered by your company .
Note: For Sections 1 and 2, do not report more than 520 hours for any individual employee, no matter how many actual hours
the employee worked during the calendar quarter.
Section 1: Complete this if you do not offer to pay any part of the cost of health care coverage for any of your employees.
Enter the total number of hours worked by all employees you employed during the FORM (Place at FIRST page)
reporting quarter and continue to “Section 3: Calculations Section,” Line A . . . . . . . . . . . . . . ___________________ Form pages
Section 1: Total hours of
uncovered employees
Section 2: Complete this if you do offer to pay part or all of the cost of health care coverage for any of your employees.
Enter the total number of hours worked by all employees in each of the following two categories:
1. Employees who are offered and eligible for coverage but choose not to accept the coverage and 3 - 4
have no other health care coverage orhave Medicaid whoor are full-time employees and
have health care coverage as individuals through the Vermont Health Benefit Exchange. . . . ___________________
Section 2, Line 1: Hours worked
by employees offered coverage but
did not accept.
2. Employees who are not eligible for the health care coverage offered to any other employees.
You may exclude hours worked by a seasonal or part-time employee as long as you offer
health care coverage to all regular, full-time employees, and the employee is covered by
a plan other than Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ___________________
Section 2, Line 2: Hours worked
by employees not offered coverage.
Section 3: Calculations Section
A. Enter the total hours worked by all employees entered in Section 1 orthe total of Lines 1
and 2 in Section 2 . NOTE: If the total is a partial hour, round down to the nearest hour. A. __________________
B. Divide the number of hours on Line A by 520 . This is your unadjusted FTE
count . NOTE: Round down to the nearest whole number. . . . . . . . . . . . . . . . . . . . . . . . . B. . __________________0
C. Number of exempted FTEs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C. . __________________4
D. Subtract Line C from Line B . This is your adjusted and reportable FTE count . Enter
this amount on Form WHT-436, Line 7 . If equal to or less than zero, report -0- . . . . . . .D. . . __________________0
E. Multiply Line D by the appropriate amount shown in the table below . This is your
quarterly Health Care Contribution. Enter this amount on Form WHT-436, Line 8,
even if -0- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E. __________________
HCC Premium per FTE Exemption (Line E)
Quarter Ending Date HCC Premium Use this
03/31/2020 - 12/31/2020 $184.42 HCC Premium
amount for the Form HC-1
03/31/2021 - 12/31/2021 $186.56
calculation on Page 1 of 1
03/31/2022 - 12/31/2022 $213.47 Line E above. Rev. 01/22
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