HRA-1                                                   Indiana Department of Revenue                            Tax 
State Form 57393 
(8-24)               Health Reimbursement Arrangement Tax Credit Worksheet                                       Year

Taxpayer Name                                                                                                    Federal Employer Identification Number

Enter total number of employees during the year.                         Enter the maximum number of employees during the year.  
Part A
If you have employees under an Federal Employer Identification Number (FEIN) other than yours, please list the FEIN and Number of Employees under all FEINs.
                 Federal Employer Identification Number                                                          Number of Employees
1.
2.
3.
4.
5.

Part B
For each employee for whom you are claiming a credit, complete all items in the row associated with the employee.
                                                                         Covered / Non-Covered Employee
       Employee Name                                                                  C = Covered Employee       Employer Designation Code
                     Social Security                    Hire Termination 
                                                                                                                                     (See instructions)
                                                 Number Date Date                     N = Non-Covered Employee

    Instructions for HRA-1, Health Reimbursement Arrangement Tax Credit Worksheet

This worksheet should be completed if you are claiming a Health         Part B Instructions
Reimbursement Arrangement tax credit. You are not required to 
provide the worksheet with your return when it is filed. However,       Enter the employee’s name and social security number for each of 
you may be asked to provide or complete this worksheet upon             your employees. List each employee only one time. Failure to list 
review of your return.                                                  an employee will result in the employee not being considered a 
                                                                        covered employee for purposes of this credit.
If you are a pass through entity (partnership, S corporation, 
estate, or trust), this credit does not flow through. In addition, if a Hire Date. Enter the date the employee was hired as MM/DD/
partnership or S corporation has a liability for pass through entity    YYYY. If an employee was hired multiple times during the taxable 
tax or composite withholding tax, this credit cannot be applied to      year, enter the last date on which the employee was hired.
reduce the tax due.
                                                                        Termination Date.
If additional sheets are necessary for Part A and Part B, include       • If the employee listed was no longer employed by you at 
additional copies of this worksheet                                       the end of the year, enter the date on which the employee 
                                                                          resigned or otherwise terminated from employment. Enter the 
Tax Year. Enter the year in which your tax year begins. For               date as MM/DD/YYYY. 
instance, if you have a fiscal year from July 1, 2024, to June 30,      • If an employee resigned or otherwise terminated multiple 
2025, enter “2024”.                                                       times during the year, enter the last termination date.
                                                                        • If an employee was still employed by you as of the end of the 
For the employee information, there are two boxes listed.                 taxable year, enter “12/31/9999”. 
Both boxes must be completed. In the first box, enter the total 
number of employees that you had during the taxable year. In            Covered/Non-Covered Employees. Enter “C” if the employee 
the second box, enter the maximum number of employees that              was covered by a health reimbursement arrangement during the 
you had at any point during the taxable year. For instance, if you      tax year. Enter “N” if the employee was not covered by a health 
had 60 employees during the year but never had more than 45             reimbursement arrangement at any time during the tax year.
employees at any time during the year, enter “60” in the first box 
and “45” in the second box.                                             Employer Designation Code. If the employee was issued a W-2 
                                                                        by you and a copy of the W-2 was supplied to the department, 
Part A Instructions
                                                                        enter “00” in this column on the row listing the employee. 
Complete this section only if you have employees that were 
                                                                        If the employee was issued a W-2 under a different FEIN than 
issued W-2s for wages paid by you as an employer and the W-2s 
                                                                        your FEIN, and that W-2 was supplied to the department, use the 
were issued by an entity with a federal employer identification 
                                                                        row for the employer in Part A. Include only the row for which the 
number (FEIN) other than your own FEIN.
                                                                        employee was included in the “Number of Employees” column in 
Enter the FEIN of any other entities that issued a W-2 to               Part A. If using rows 1 through 9, include a leading zero (e.g., row 
your employees for your wages. In the box for the number of             1 is employer designation code “01”, etc.).
employees, enter the number of employees that were issued 
                                                                        If an employee was issued a W-2 and the W-2 was not supplied to 
W-2s for your wages under that FEIN. However, if an employee 
                                                                        the department, enter “99” in this column.
had W-2s issued under two different FEINs, include the employee 
only once:                                                              Note. If you are a fiscal year filer, enter the employer designation 
• If you issued a W-2 to the employee and the W-2 issued by             code for which you expect the W-2s ultimately will be issued.
  you was supplied, or will be supplied, to the department, do 
  not count the employee under the “Number of Employees” for 
  any employer in Part A.
• If you did not issue a W-2 to the employee and two or more 
  employers listed in Part A issued W-2s to an employee, 
  include them in the “number of employees” only for the first 
  employer that:
  ο is listed, and
  ο supplied or will supply a W-2 to the department.