Page 3
Vermont Department of Taxes PO Box 547 Montpelier, VT 05601-0547
Phone: (802) 828-2551
HEALTH CARE CONTRIBUTIONS WORKSHEET
VT Form
HC-1
Do not return this form to the
Vermont Department of Taxes.
You must retain this form for your
records for three years.
Employer FEIN Quarter / Year
Uncovered Employee Count:
Did you have 5 or more full-time equivalent (FTE) employees who were all age 18 and
older in the previous quarter?
.................................................. Yes No
If you answered NO, check this box to certify no Health Care Fund Contributions
will be due for this quarter.
If you answered YES, complete Section 1 or 2 below (not both) depending on the
health care coverage offered by your company.
Note: For Sections 1 and 2, do not report more than 520 hours for any individual employee, no matter how many actual hours
the employee worked during the calendar quarter.
Section 1: Complete this if you do not offer to pay any part of the cost of health care coverage for any of your employees.
Enter the total number of hours worked by all employees you employed during the
reporting quarter and continue to “Section 3: Calculations Section,” Line A
.............. ___________________
Section 1: Total hours of
uncovered employees
Section 2: Complete this if you do offer to pay part or all of the cost of health care coverage for any of your employees.
Enter the total number of hours worked by all employees in each of the following two categories:
1. Employeeswhoareoeredandeligibleforcoveragebutchoosenot to accept the coverage and
have no other health care coverage or have Medicaid or who are full-time employees and
havehealthcarecoverageasindividualsthroughtheVermontHealthBenetExchange. ... ___________________
Section 2, Line 1: Hours worked
by employees offered coverage but
did not accept.
2. Employees who are noteligibleforthehealthcarecoverageoeredtoanyotheremployees.
You may exclude hours worked by a seasonal or part-time employee as long as
youoer
health care coverage to all regular, full-time employees, and the employee is covered by
a plan other than Medicaid. .................................................... ___________________
Section 2, Line 2: Hours worked
by employees not offered coverage.
Section 3: Calculations Section
A. Enter the total hours worked by all employees entered in Section 1 or the total of Lines 1
and 2 in Section 2. NOTE: If the total is a partial hour, round down to the nearest hour. A. __________________
B. Divide the number of hours on Line A by 520. This is your unadjusted FTE
count. NOTE: Round down to the nearest whole number. .........................B. __________________
C. Number of exempted FTEs ..................................................C. __________________
D. Subtract Line C from Line B. This is your adjusted and reportable FTE count. Enter
this amount on Form WHT-436, Line 7. If equal to or less than zero, report -0-. ........D. __________________
E. Multiply Line D by the appropriate amount shown in the table below. This is your
quarterly Health Care Contribution. Enter this amount on Form WHT-436, Line 8,
even if -0-. ...............................................................E. __________________
4
Form HC-1
Page 1 of 1
Rev. 01/22
03/31/2020 - 12/31/2020 $184.42
03/31/2021 - 12/31/2021 $186.56
03/31/2022 - 12/31/2022 $213.47
HCC Premium per FTE Exemption (Line E)
HCC PremiumQuarter Ending Date
Use this
HCC Premium
amount for the
calculation on
Line E above.
FORM (Place at FIRST page)
Form pages
3 - 4
0
0
Page 4
Preparer’s Telephone Number Preparer’s PTIN or EIN
FORM (Place at LAST page)
Form pages
3 - 4
A. Number of full-time employees as of the last day of this quarter. ...A. ________________
B. Number of part-time employees as of the last day of this quarter. ..B. ________________
C. Check here if this is an AMENDED return. ...................C.
PART I WAGE WITHHOLDING
1. Total Vermont wages paid this quarter ............1. ______________________. ____
2. Total Vermont tax withheld from wages this quarter ............................ . . . . .2. ______________________. _____
PART II NONWAGE WITHHOLDING
3. Total nonwage payments subject to withholding
this quarter .................................. 3. ______________________. ____
4. Total Vermont tax withheld from nonwage payments this quarter ............. . . . . . . . . .4. ______________________. _____
5. Total Vermont tax withheld this quarter (Add Lines 2 and 4) .............. . . . . . . . . .5. ______________________. _____
PART III HEALTH CARE CONTRIBUTIONS
6. Check here to certify that no Health Care Contribution is due based on the rules governing this reporting.
7. Adjusted Uncovered FTE (from Form HC-1,
Health Care Contributions Worksheet, Line D) ......7. ___________________________
8. Total Health Care Contributions Due (from Form HC-1, Line E). . . . . . . . . . . . . . . . . . . . . . .8. ______________________. _____
PART IV BALANCE
9. Total due (Add Lines 5 and 8) ......................................... . . . . . . . . .9. ______________________. _____
10. Vermont withholding tax already paid this quarter ......................... . . . . . . . .10. ______________________. _____
11. Refund (If Line 10 is greater than Line 9, subtract Line 9 from Line 10.) . . . . . . . . . . . . . . .11. ______________________. _____
12. TOTAL Withholding Tax and Health Care Contributions Due
(If Line 9 is greater than Line 10, subtract Line 10 from Line 9.) ............. . . . . . . . .12. ______________________. _____
Form WHT-436
Rev. 12/20
*204361100*
*204361100*
Vermont Department of Taxes PO Box 547 Montpelier, VT 05601-0547
Phone: (802) 828-2551
5454
Business Name Federal ID Number
Address Vermont Account ID
City State ZIP Code
Foreign Country (if not United States)
Reporting Period - Check only ONE. If due date falls on a weekend or holiday, return is due the next business day. Year being reported (YYYY)
OCT - DEC
(due Jan. 25)
JUL - SEP
(due Oct. 25)
APR - JUN
(due Jul. 25)
JAN - MAR
(due Apr. 25)
For Department Use Only
Check here if authorizing the Vermont
Department of Taxes to discuss this return
and attachments with your preparer.
PART V SIGNATURE
I hereby certify that I have examined this return and to the best of my knowledge and belief it is true, correct, and complete.
Signature of Ofcer or Authorized Agent Date Preparer’s Signature Date
Title Telephone Number Firm’s name (or yours, if self-employed) and address
VT Form
WHT-436
QUARTERLY WITHHOLDING
RECONCILIATION and
HEALTH CARE CONTRIBUTION
WHT-
0
0.00
Clear period info only
Clear ALL fields
Save and Print