Alabama Form 4020 : Small Business Health Insurance Deduction Information Form

If a small business that is registered in the State of Alabama wishes to file its healthcare insurance deduction information, they form has to be used. Complete the form and file it while keeping each tax year separate.

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A	LA BA M A	D	EP ARTM E\f T OF	R	EV E\f UE	
I\f DIV ID U AL	& C	O RPO RA TE	TA X	D	IV IS IO \f	
Sma ll Bu si n ess \b ea lt h  I n suran ce  
D edu ctio n I n fo rm atio n  Fo rm	
E m plo ye r 	(P l\b as\b  c h\bc\f b ox if  s ta t\b m \bnt a p pli\b s to  y o u.)	
�	   M y c om pany e m plo ys le ss th an 2 5 e m plo ye es, a nd  I c om ply  w it h  th e r u le s a s d esc rib ed  in
 R eg ula tio n 8 10-\b -1 5.\b -.0 1 a d m in is te re d  b y th e \f la b am a D ep artm ent o f R eve nue.
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m y  k n ow le d g e.
_____________________________________________  _____________________________ ________________
S ig natu re                                                                       Tit le                                                 Date	
E m plo ye e 	(P l\b as\b  c h\bc\f a ll  b ox\b s th at a p ply  to  y o u.)	
�	   I a m  a  r e sid ent o f \f la b am a.	
�	  I e arn  n o m ore  th an $ 50,0 00 in  w ag es fr o m  th e a b ove  “ q ualif y in g  e m plo ye r. ”	
�	   I h ave  to ta l  a d ju ste d  g ro ss in com e o f n o m ore  th an $ 75,0 00 if  fi lin g  s in g le  o r $ 150,0 00 if  m arrie d
 filin g  jo in tly .
U nder p en alt ie s o f p erju ry ,  I d ecla re  t h at t h e in fo rm atio n a b ove is  t r u e a n d c o rre ct t o  t h e b est o f
m y  k n ow le d g e.
___________________________________________________________  _____________________________
S ig natu re                                                                                                Date
E m plo ye rs  a \f d E m plo ye es s \b ould  e ac\b  r e ta i\f  a  c o py o f t \b is  f o rm  f o r t \b eir  r e co rd s.	
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\f O RM
40\b0	(6 /1 2)