QUALIFIED HEALTH INSURANCE PREMIUMS WORKSHEET FOR MO-A, LINE 11
Complete this worksheet and attach it to Form MO-1040 if you included health insurance premiums paid as an itemized
deduction or had health insurance premiums withheld from your social security benefits.
If you had premiums withheld from your social security benefits, complete Lines 1 through 4 to determine your taxable
percentage of social security income and the corresponding taxable portion of your health insurance premiums included
in your taxable income.
1. Enter the amount from Federal Form 1040A, Line 14a, or Federal Form 1040, Line
20a. If $0, skip to Line 6 and enter your total health insurance premiums paid. . . . . . . 1. _____________
2. Enter amount from Federal Form 1040A, Line 14b or Federal Form 1040,
Line 20b. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. _____________
3. Divide Line 2 by Line 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. _____________%
Yourself Spouse
4. Enter the health insurance premiums withheld from your social
security income. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Y. _____________ 4S. _____________
5. Multiply the amounts on Line 4Y and 4S by the percentage on Line 3. . . . . . 5Y. _____________ 5S. _____________
6. Enter the total of all other health insurance premiums paid, which
were not included on 4Y or 4S. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Y. _____________ 6S. _____________
7. Add the amounts from Lines 5 and 6. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Y. _____________ 7S. _____________
8. Add the amounts from Lines 7Y and 7S. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Y. _____________
9. Divide Line 7Y and 7S by the total found on Line 8. If you itemized on your
federal return and your federal itemized deductions included health insurance
premiums as medical expenses, go to Line 10. If not, go to Line 15. . . . . . . . . . 9Y. ____________% 9S. ____________%
10 . Enter the amount from Federal Schedule A, Line 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10. _____________
11. Enter the amount from Federal Schedule A, Line 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11. _____________
12. Divide Line 11 by Line 10 (round to full percent). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12. _____________%
13. Multiply Line 8 by percent on Line 12. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13. _____________
14. Subtract Line 13 from Line 8. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14. _____________
15. Enter your federal taxable income from Federal Form 1040A, Line 27, or
Federal Form 1040, Line 43. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15. _____________
16. If you itemized on your federal return and completed Lines 10 through 14 above,
enter the amount from Line 14 or Line 15, whichever is less.
If not, enter the amount from Line 8 or Line 15, whichever is less. . . . . . . . . . . . . . . . . . . . 16. _____________
17. Multiply Line 16 by the percentage on Line 9Y and Line 9S.
Enter the amounts on Line 17Y and 17S of this worksheet on Line 11
of Form MO-A. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Y. _____________ 17S. ____________
A. Enter the amount paid for qualified long-term care insurance policy. ...... A) $___________
If you itemized on your federal return and your federal itemized
deductions included medical expenses, go to Line B. If not, skip to H.
B. Enter the amount from Federal Schedule A, Line 4. ............................ B) $___________
C. Enter the amount from Federal Schedule A, Line 1. ............................ C) $___________
D. Enter the amount of qualified long-term care included on Line C. ..... D) $___________
E. Subtract Line D from Line C. .............................................................. E) $___________
F. Subtract Line E from Line B. If amount is less than zero, enter “0”...... F) $___________
G. Subtract Line F from Line A. .............................................................. G) $___________
H. Enter Line G (or Line A if you did not have to complete Lines B through G) on Form MO-1040, Line 17
Attach a copy of your Federal Form 1040 (pages 1 and 2) and Federal Schedule A
(if you itemized your deductions).
Worksheet for Long-term Care InsuranCe DeDuCtIon
(Revised 12-2013)
