KANSAS                                                                         191518
K-57(Rev. 8-19)                        SMALL EMPLOYER HEALTHCARE CREDIT

                For the taxable year beginning,   _____________________ , 20 _____        ; ending __________________________ , 20              _______ .

 Name of taxpayer (as shown on return)                                                             Employer ID Number (EIN)

Date you began participation in this plan:______________________________________________
Those employers who started a small employer health benefit plan on or after January 1, 2005 must answer the following question:
Did this employer contribute to any health insurance premium or health savings account on behalf of an employee who is to be covered 
by the employer’s contribution within the preceding two years of the effective date of the employer’s small employer health benefit plan?
o No    o Yes   (If yes, you do not qualify for this credit.)

 PART A — COMPUTATION OF ELIGIBLE EMPLOYEE AMOUNT (C Corporations only)
Complete the appropriate schedule. If the employer established this plan after December 31, 2004, complete Schedule I. If the
employer established this plan prior to January 1, 2005, complete Schedule II.
                                             SCHEDULE I                                                                     SCHEDULE II
                (a)                        (b)                   (c)                      (d)                           (e)                              (f)
                Number of eligible      FIRST 12 MONTHS          NEXT 12 MONTHS           NEXT 12 MONTHS                Number of eligible      Maximum allowed.
                employees for the month Multiply amount in (a) by  Multiply amount in (a) by  Multiply amount in (a) by employees for the month Multiply amount in (e) by $35.
                                        the lesser of $70 or the the lesser of $50 or the the lesser of $35 or the 
                                        actual amount paid per   actual amount paid per   actual amount paid per 
 (By Tax Year)                          employee.                employee.                employee.
 1. 1st month
 2. 2nd month
 3. 3rd month
 4. 4th month
 5. 5th month
 6. 6th month
 7. 7th month
 8. 8th month
 9. 9th month
10.10th month
11.11th month
12.12th month
13.Total

If you completed SCHEDULE I, proceed to LINE 18.
If you completed SCHEDULE II, proceed to LINE 14.
14. Enter actual expense for the tax period.                                                                                14.                 ________________________
15. Maximum credit allowed (multiply line 14 by 50% and enter the result here).                                             15.                 ________________________
16. Enter the lesser of line 13, column (f) or line 15.                                                                     16.                 ________________________

17. Year of participation:  1st & 2nd year o 100%                3rd year o 75%           4th year o 50%                    5th year o 25%

 PART B — COMPUTATION OF CREDIT
18. Credit allowable for this tax year. From SCHEDULE I – enter amount from line 13, columns (b), (c),
  and/or (d). From SCHEDULE II – multiply line 16 by the appropriate percentage from line 17 and
  enter result. Enter this amount on the appropriate line of Form K-120.                                                    18.                 ________________________

                                 INSTRUCTIONS FOR SCHEDULE K-57

        GENERAL INFORMATION                                                LINES 1 through 12 – Schedule I (Plans after 12/31/2004)
K.S.A. 40-2246 allows an income tax credit to those employers              Column (a): Enter number of eligible employees covered by this 
that make contributions to a health savings account of an eligible         plan for each month of the employer’s tax year.
covered employee after 12/31/2004. The credit is $70 per month per         Column (b): If you established or made contributions during this tax 
eligible covered employee for the first 12 months of participation,        year which constitutes the FIRST 12 MONTHS of participation, 
$50  per  month  per  eligible  covered  employee  for  the  next  12      multiply  the  number  of  eligible  employees  for  each  month  of 
months  of  participation  and  $35  per  month  per  eligible  covered    participation by the lesser of $70 or the actual amount paid per 
employee for the next 12 months of participation.                          employee.
Any  small  employer  (defined  by  K.S.A.  40-2209d)  having              Column (c): If you established or made contributions during this tax 
between 2 and 50 employees may establish a health benefit plan             year which constitutes the NEXT 12 MONTHS of participation, 
for  the  purpose of  providing  a  plan  as  described  under  K.S.A.     multiply  the  number  of  eligible  employees  for  each  month  of 
40-2240 covering  such employer’s eligible  employees and such             participation by the lesser of $50 or the actual amount paid per 
employees’  family  members.  For  plans  established prior to             employee.
1/1/2005, a certificate issued by the Commissioner of Insurance            Column (d): If you established or made contributions during this tax 
entitling a “small employer” to claim the tax credit authorized by         year which constitutes the NEXT 12 MONTHS of participation, 
K.S.A. 40-2246 must have been obtained.                                    multiply  number  of  eligible  employees  for  each  month  of 
For tax year 2013, and all tax years thereafter, credits shall be          participation by the lesser of $35 or the actual amount paid per 
                                                                           employee. (The total of columns b, c and d should be only 12 
available  to  only  corporations  subject  to  the  Kansas  corporate 
                                                                           months.)
income  tax (i.e., C corporations).  Credits  are  not available  to 
individuals, partnerships, S corporations, limited liability companies,    LINES 1 through 12 – Schedule II (Plans prior to 1/1/2005)
and other pass-through entities.                                                       Enter number of eligible employees covered by this 
                                                                           Column (e):
An eligible employee is one who is employed for an average of              plan for each month of the employer’s tax year.
at least 30 hours per week and elects to participate in one of the 
benefit plans provided under this act, and includes individuals who        Column (f): Multiply number of eligible employees for each month 
                                                                           by $35.
are sole proprietors, business partners, and limited partners who 
own the business. Eligible employee does not include individuals:          LINE 13 –  Add  lines  1  through  12  and  enter  result.  If  the  plan 
1) engaged  as  independent  contractors;  2)  whose  periods  of          was established after 12/31/2004 and Schedule I is complete, 
employment are on an intermittent or irregular basis; or, 3) who           proceed to line 18. If established prior to 1/1/2005 and Schedule 
have been employed by the employer for fewer than 90 days.                 II is complete, proceed to line 14.
A health savings account means a trust created or organized                LINE 15 – To figure maximum credit allowed multiply line 14 by 50%.
in the United States as a health savings account exclusively for the       LINE 16 – Enter the lesser of line 13, column (f) or line 15.
purpose of paying the qualified medical expenses of the account            LINE 17 – Check the appropriate box for the number of tax years 
beneficiary,  but  only  if  the  written  governing  instrument  creating you have participated in this credit.
the  trust  meets  the  requirements  specified  by  the  Medicare, 
prescription  drug,  improvement  and  modernization  act  of  2003,       PART B – COMPUTATION OF ELIGIBLE EMPLOYEE AMOUNT
Pub. L. No. 108-173, 117 Stat. 2067.                                       LINE 18 – If the plan was established after 12/31/2004 and you 
As a condition to participate as a member of any small employer            completed Schedule I, enter the amount from line 13, columns 
health benefit plan, an employer shall have not contributed within         (b), (c), and/or (d). If the plan was established prior to 1/1/2005 
the preceding two years to any health insurance premium or health          and you completed Schedule II, multiply line 16 by the appropriate 
savings account on behalf of an employee who is to be covered              percentage from line 17. Enter result here and on the appropriate 
by the employer’s contribution other than a contribution by an             line of Form K-120.
employer to a health insurance premium or health savings account 
within the preceding two years solely for the benefit of the employer                  TAXPAYER ASSISTANCE
or the employer’s dependents.                                              For  questions  or  assistance  in  establishing  a  Small  Employer 
If the credit exceeds the current year’s tax liability, the unused         Health Benefit Plan, contact the Kansas Insurance Department:
portion shall be refunded to the taxpayer.                                                       420 SW 9th St
Addition Modification. The employer is required to reduce any                                  Topeka KS 66612-1678
expense deduction that is included in federal taxable income for the                           Phone: 785-296-3071
tax year by the dollar amount of the credit.                                                   Fax: 785-296-7850
Documentation. Retain  your monthly  insurance  billings  with 
your records as the Department of Revenue reserves the right to            For assistance in completing this schedule contact the Kansas 
request additional information as necessary.                               Department of Revenue:
                                                                                       Taxpayer Assistance Center
        SPECIFIC LINE INSTRUCTIONS                                                             Scott Office Building
Begin by completing the information at the top of the schedule.                                  120 SE 10th Ave
                                                                                                 PO Box 750260
   PART A – COMPUTATION OF ELIGIBLE EMPLOYEE AMOUNT                                            Topeka KS 66699-0260
             (C Corporations only)                                                             Phone: 785-368-8222
Complete the appropriate schedule. If the employer established                                 Fax: 785-291-3614
this plan after 12/31/2004, complete Schedule I. If it was established     Additional copies of this credit schedule and other tax forms 
prior to 1/1/2005, complete Schedule II.                                   are available from our website at: ksrevenue.gov