- 1 -
|
0 0 0 1 1 1 1 0
0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4 5 5 5 5 5 5 5 5 5 5 6 6 6 6 6 6 6 6 6 6 7 7 7 7 7 7 7 7 7 7 8 8 8 8 8 80 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4 5 5 5 5 5 5 5 5 5 5 6 6 6 6 6 6 6 6 6 6 7 7 7 7 7 7 7 7 7 7 8 8 8 8 8 80 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4 5 5 5 5 5 5 5 5 5 5 6 6 6 6 6 6 6 6 6 6 7 7 7 7 7 7 7 7 7 7 8 8 8 8 8 80 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4 5 5 5 5 5 5 5 5 5 5 6 6 6 6 6 6 6 6 6 6 7 7 7 7 7 7 7 7 7 7 8 8 8 8 8 80
1 1 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 52 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 52 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 52 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 51
0 0 0 4 4 4 4 0
0 0 0 5 5 5 5 0 Form Qualified Health Insurance Premiums Social Security Number
0 0 0 6 6 6 6 0 Worksheet for MO-A
0 0 0 7 7 7 7 0 5695 - -
0 0 0 8 8 8 8 0 Spouse’s Social Security Number
0 0 0 9 9 9 9 0
1 1 1 0 0 0 0 1 - -
1 1 1 1 1 1 1 1
1 1 1 2 2 2 2 1 Complete this worksheet and attach it, along with proof of premiums paid, to Form MO-1040 if you included health insurance premiums paid as an
1 1 1 3 3 3 3 1 itemized deduction or had health insurance premiums withheld from your social security benefits.
1 1 1 4 4 4 4 1
1 1 1 5 5 5 5 1 If you had premiums withheld from your social security benefits, complete Lines 1 through 4 to determine your taxable percentage of social security
1 1 1 6 6 6 6 1 income and the corresponding taxable portion of your health insurance premiums included in your taxable income.
1 1 1 7 7 7 7 1
1 1 1 8 8 8 8 1 1. Enter the amount from Federal Form 1040 or Federal Form 1040-SR, Line 6a. If $0, skip to Line 6 and enter
1 1 1 9 9 9 9 1 your total health insurance premiums paid ...................................................... 1 . 00
2 2 2 0 0 0 0 2
2 2 2 1 1 1 1 2 2. Enter amount from Federal Form 1040 or Federal Form 1040-SR, Line 6b ............................ 2 . 00
2 2 2 2 2 2 2 2
2 2 2 3 3 3 3 2 3. Divide Line 2 by Line 1 ..................................................................... 3 %
2 2 2 4 4 4 4 2
2 2 2 5 5 5 5 2 Yourself (Y) Spouse (S)
2 2 2 6 6 6 6 2 4. Enter the health insurance premiums withheld from your social
2 2 2 7 7 7 7 2 security income ............................................. 4Y . 00 4S . 00
2 2 2 8 8 8 8 2
2 2 2 9 9 9 9 2 5. Multiply the amounts on Line 4Y and 4S by the percentage on Line 3. ... 5Y . 00 5S . 00
3 3 3 0 0 0 0 3
3 3 3 1 1 1 1 3 6. Enter the total of all other health insurance premiums paid, which
3 3 3 2 2 2 2 3 were not included on 4Y or 4S .................................. 6Y . 00 6S . 00
3 3 3 3 3 3 3 3
3 3 3 4 4 4 4 3 7. Add the amounts from Lines 5 and 6 ............................. 7Y . 00 7S . 00
3 3 3 5 5 5 5 3
3 3 3 6 6 6 6 3 8. Add the amounts from Lines 7Y and 7S ....................................................... 8 . 00
3 3 3 7 7 7 7 3
3 3 3 8 8 8 8 3 9. Divide Line 7Y and 7S by the total found on Line 8. If you itemized
3 3 3 9 9 9 9 3 on your federal return and your federal itemized deductions included
4 4 4 0 0 0 0 4 health insurance premiums as medical expenses, go to Line 10.
4 4 4 1 1 1 1 4 If not, go to Line 15 ........................................... 9Y % 9S %
4 4 4 2 2 2 2 4
4 4 4 3 3 3 3 4 10. Enter the amount from Federal Schedule A, Line 1 ............................................... 10 . 00
4 4 4 4 4 4 4 4
4 4 4 5 5 5 5 4 11. Enter the amount from Federal Schedule A, Line 4................................................ 11 . 00
4 4 4 6 6 6 6 4
4 4 4 7 7 7 7 4 12. Divide Line 11 by Line 10 (round to full percent) ................................................. 12 %
4 4 4 8 8 8 8 4
4 4 4 9 9 9 9 4 13. Multiply Line 8 by percent on Line 12 .......................................................... 13 . 00
4 4 4 0 0 0 0 4
5 5 5 1 1 1 1 5 14. Subtract Line 13 from Line 8................................................................. 14 . 00
5 5 5 2 2 2 2 5
5 5 5 3 3 3 3 5 15. Enter your federal taxable income from Federal Form 1040 or Federal Form 1040-SR, Line 15............. 15 . 00
5 5 5 4 4 4 4 5
5 5 5 5 5 5 5 5 16. If you itemized on your federal return and completed Lines 10 through 14 above, enter the amount from
5 5 5 6 6 6 6 5 Line 14 or Line 15, whichever is less. If not, enter the amount from Line 8 or Line 15, whichever is less ...... 16 . 00
5 5 5 7 7 7 7 5
5 5 5 8 8 8 8 5 17. Multiply Line 16 by the percentage on Line 9Y and Line 9S.
5 5 5 9 9 9 9 5 Enter the amounts on Line 17Y and 17S of this worksheet on Line 13
5 5 5 0 0 0 0 5 of Form MO-A ............................................... 17Y . 00 17S . 00
6 6 6 1 1 1 1 6
6 6 6 2 2 2 2 6 Ever served on active duty in the United States Armed Forces?
If yes, visit dor.mo.gov/military/ to see the services and benefits we offer to all eligible
6 6 6 3 3 3 3 6 military individuals. A list of all state agency resources and benefits can be found at Form 5695 (Revised 12-2023)
6 6 6 4 4 4 4 6 veteranbenefits.mo.gov/state-benefits/.
6 6 6 5 5 5 5 6
6 6 666 6 6 6
|