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Before beginning the on-line application: Please read the guidance documents for the Wellness Tax Credit prior to completing the form. They can be found at this site: http://www.mass.gov/wellnesstaxcredit

The entire application must be completed in one on-line session. Therefore please print out the application and complete it in hard copy prior to filling in the on-line application.
1. Have the person with legal authority review the hard copy application as to its accuracy and honesty and sign the document.
2. Maintain the signed-hard copy of the application for your records.

Application for Certification of Wellness Program Tax Credit

Contact and Demographic Information (all questions must be completed in this section)

1. Name of business:

2. Mailing address:    
-


4. Type of business entity:






 
 
 
Trust - Definition
An arrangement created either by will or inter vivos (lifetime) declaration whereby trustees take title to property (real or personal, tangible or intangible) for the purpose of protecting and conserving it for the beneficiaries.
S Corporation - Definition
An S Corporation is a special type of corporation that is treated for tax purposes as a hybrid between a corporation and a partnership. An S Corporation is allowed to have a limited number of shareholders, and those shareholders are usually individual persons. Generally, the income, loss, deductions and credits of an S corporation flow through to the shareholders for Massachusetts tax purposes. The S corporation itself is also subject to corporate-level taxes.
Estate - Definition
Generally, this term refers to the property, real or personal, tangible or intangible, wherever situated, that an individual owns as of his or her date of death. Typically, a decedent’s estate is administered by personal representative (administrator or executor) prior to distribution to the heirs or beneficiaries.
 

4a. Is this a pass-through entity?     Show Definition
An entity whose income, loss, deductions and credits flow through to members for Massachusetts tax purposes. General partnerships, limited partnerships, limited liability partnerships, limited liability companies with members treated as a partner under Massachusetts tax law, S corporations, estates not taxed at the entity level, and trusts not taxed at the entity level are all pass-through entities. Partners, owners, shareholders, or beneficiaries of a pass-through entity are called 'members.'

5. Name, title and contact information of person completing this form:    
-
 
6. Your Organization's Industry Type:






















Eligibility Requirements

7. Do you offer health benefits to employees?
8. Total number of employees (including full time, part time and self and business partner). Must be less than or equal to 200 to qualify.



9. Do the majority of your employees work in Massachusetts?
10. Is your business in compliance with all legal obligations of employers including but not limited to those enumerated in M.G.L. c. 149
11. Is the taxpayer incorporated in Massachusetts?



Components of Wellness Programs

12. What is the maximum tax credit amount you intend to seek for the 2014 tax year? (Enter amount without comma)

Amount cannot exceed $10,000. The law states: "the credit allowed . . . shall be equal to 25 per cent of the costs associated with implementing a program . . . with a maximum credit of $10,000 per business in any 1 fiscal year."

Eligible costs for a Wellness Tax Credit: Expenses related to employee wellness that are directly incurred by the eligible business qualify as dollars spent on wellness. If elements of a wellness program are provided as part of an insurance program, documentation will be required to identify the retail value of the services provided. The following are considered eligible program costs:

  • Salary or portion there of, for person(s) planning, participating on wellness committees, managing and/ or implementing the program. To qualify, the person’s job description must include the specifics of the responsibilities.
  • Awareness and education program costs, i.e., seminar costs, newsletters, posters produced by a third party.
  • Vendor costs related to providing health risk assessment of employees or training, education or behavioral interventions that address the health risks of employees.
  • Behavior change program costs that are not provided by health plan, i.e., campaign or challenge costs such as pedometers, program materials, online tools, health coaching, nicotine replacement therapy, gym memberships.
  • Costs associated with the promotion and access to community-based, insurer or vendor sponsored programs, resources and facilities that are part of the formal wellness plan.
  • Costs associated with changes to the worksite that encourages healthy lifestyle choices, i.e., improvements to stairs, educational or point of purchase materials for healthy food choices in vending machines and cafeterias, break room improvements or furnishings such as dishwasher or microwave. Automatic External Defibrillator (AED) installation, signage for tobacco free worksite, lactation room furnishings, meeting space for educational seminars and workshops, and on-site classes.
  • Incentives for employee participation in wellness activities. Examples include gift cards, well days off, health plan and cash.
  • Paid work time for health screenings, wellness check-ups with private physicians or appointments for managing chronic conditions such as diabetes or asthma for themselves or family members, participation in health-related meetings.
  • Costs associated with injury prevention, e.g. safety education subscriptions, equipment and signage to avoid hazards, pilot testing of products made with safer materials, feasibility studies for safety designs.
  • Training costs, i.e., safe lifting, repetitive motion injury prevention, relaxation training, assertiveness, communication, time management.
  • Data collection costs, such as assessment tools (needs and interest survey, health risk assessment, environmental scan), process measures such as focus groups participation.
  • Evaluation costs, any cost associated with evaluating program impact and outcomes, i.e., human resources data analysis such as absenteeism or productivity, participation rates, employee satisfaction.

Infrastructure to Support Wellness Programs

In the following sections please provide information on your business’ Wellness Program efforts during 2014.

13. Was there an identified Wellness Champion (The role of Wellness Champion is included in that individual's stated job responsibilities)
14. Was there at least one communication that was distributed to all employees that fully described available wellness options
and assured employees that all personal information is kept confidential and that participation is entirely voluntary?

15. Data was collected on current employee health status:





16. There was an existing process to identify employee wellness and health interests/needs through:



17. What were the top three most important health issues and/or interests of employees:











Program Interventions

18. What health issues were addressed through program interventions? At least one topic must match a topic
checked in question 17. Check at least one box












Awareness/Education Component

19. What awareness and educational components did you provide? Check all that apply:




Encouraging Individual Behavior Change Component

20. What did you do to encourage employees to improve their own healthy behaviors? Check all that apply:


Supportive Environment Component

21. What did you do to create a supportive environment in the workplace to help employees change behavior or
reduce health risks in the workplace? Check all that apply:


















Participation Component Note on Non-Discrimination

An entity whose income, loss, deductions and credits flow through to members for Massachusetts tax purposes. General partnerships, limited partnerships, limited liability partnerships, limited liability companies with members treated as a partner under Massachusetts tax law, S corporations, estates not taxed at the entity level, and trusts not taxed at the entity level are all pass-through entities. Partners, owners, shareholders, or beneficiaries of a pass-through entity are called 'members.'
22. What percentage of employees participated in any one aspect of the wellness program?

23. How did you measure participation rates?


Authority to Share Information and Attestation Component: Please note that your business may be audited for compliance to labor laws and/or for tax purposes.  If you fail the audit, your Wellness Certification may be denied.

I hereby swear or affirm under the penalties of perjury that the above named business:

  • Complies with all legal obligations of employers, including M.G.L. c.149 & all applicable labor, licensing and tax laws;
  • Has purchased workers’ compensation insurance as required by law;
  • Has not been cited by the US Department of Labor OSHA for willful or repeat violations within the last 5 years; and
  • Has not been cited by federal or state authorities for violation of wage and hour laws within the last 5 years.

Provide Attestation from corporate officer

I hereby swear or affirm under the penalties of perjury that I have the legal authority to bind the business entity and that the information above is true and accurate to the best of my knowledge and belief.




WARNING: STATE LAW STATES THAT: M.G.L. c. 266,67B, FALSE, Fictitious or Fraudulent Claims Made to the Commonwealth or Municipality. Whoever makes or presents to any employee, department, agency or public instrumentality of the Commonwealth or of any political subdivision thereof, any claim upon or against any department, agency, or public instrumentality of the Commonwealth, or any political subdivision thereof, knowing such claim to be false, fictitious, or fraudulent, shall be punished by a fine of not more than two thousand dollars or by imprisonment in the state prison for not more than five years, or in the house of correction for not more than two and one-half years, or both.

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