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4 FINAL DRAFT — 10/2/23 4
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6 *231811* 6
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2023 Schedule M1LTI, Long-Term Care Insurance Credit
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10 YOUR FIRST NAME,INITXXXXXXXXXX LAST NAMEXXXXXXXXXXXXXXXXXXX 999999999 10
11 Your First Name and Initial Last Name Social Security Number 11
12 If you (or your spouse, if filing a joint return) paid premiums in 2023 for a qualified long-term care insurance policy, complete this schedule 12
13 to determine the amount of the credit you may claim when filing Form M1, Individual Income Tax . 13
14 To qualify for this credit, both of these must apply to your long-term care insurance policy: 14
15 • It qualifies as an itemized deduction on Schedule M1SA, Minnesota Itemized Deductions, regardless of income limitations 15
16 • It has a lifetime long-term care benefit limit of $100,000 or more 16
17 There are no separate instructions for Schedule M1LTI. 17
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19 Policy Information (only one qualifying policy per person): 19
20 Name of Insured Insurance Company Policy Number 20
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22 NAME OF INSURED XXXXXXXXXXXXXX INSURANCE COMPANY XXXXXX 1234567891010101 22
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24 NAME OF INSURED XXXXXXXXXXXXXX INSURANCE COMPANY XXXXXX 1234567891010101 24
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26 Provide the information in the appropriate column for each insured person. If you are 26
27 filing a joint return and both you and your spouse are covered by one policy, use half Round amounts to the nearest whole dollar. 27
28 of the premiums in column A and half in column B (below). 28
29 A —You B —Spouse 29
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32 1 Premiums paid in 2023 for the qualifying long-term care insurance policy . . . . . . . . . . . . . . . . . 1 12345678 12345678 32
33 Did you file Schedule M1SA? 33
34 • If no, skip lines 2, 3, and 4, and enter amounts from line 1 on line 5. 34
35 • If yes, continue with line 2. 35
36 2 Amount of premiums paid on this policy that are included on line 1 of Schedule M1SA . . . . . . . 2 12345678 12345678 36
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38 3 Amount from line 4 of Schedule M1SA (If you and your spouse are claiming 38
39 premiums paid, enter half of this amount in each column) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 12345678 12345678 39
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41 4 Amount from line 2 or line 3, whichever is less . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 12345678 12345678 41
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43 5 Subtract line 4 from line 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 12345678 12345678 43
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45 6 Multiply line 5 by 25% (.25) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 12345678 12345678 45
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47 7 The maximum credit is $100 per person . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7. . 100 100 47
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49 8 Amount from line 6 or line 7, whichever is less . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 12345678 12345678 49
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51 9 Add line 8, columns A and B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 12345678 51
52 Full-year residents: Also enter this amount on line 2 of Schedule M1C. 52
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54 Part-year Residents and Nonresidents 54
55 10 Multiply line 9 by line 30 of Schedule M1NR. 55
56 Enter the result here and on line 2 of Schedule M1C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 12345678 56
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58 You must include this schedule with your Form M1. 58
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63 9995 63
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