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4 NEAR FINAL DRAFT 8/1/24 4
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6 *241561* 6
7 2024 Schedule M1PSC, Credit for Parents of Stillborn Children 7
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9 Complete this schedule if all of these are true: 9
10 • You experienced the birth of a stillborn child in 2024 10
11 • You received a Certificate of Birth Resulting in Stillbirth from Minnesota 11
12 • The child would have been your dependent in 2024 if they had not been stillborn 12
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15 FIRST NAME, INITXXXXXXXXXXXXX YOUR LAST NAMEXXXXXXXXX 999999999 15
16 Your First Name and Initial Last Name Social Security Number 16
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18 A theDid experience you birth aof stillborn 2024?in child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .X . Yes NoX 18
19 (If you answered no, STOP HERE. You do not qualify for this credit.) 19
20 haveB Do you a Certificate Birthof Resulting Stillbirthin from the Minnesota Department Health?of . . . . . . . . . . . . . . . YesX NoX 20
21 (If you answered no, but experienced the birth of a stillborn child in Minnesota in 2024, see instructions.) 21
22 C you Would have claimed the child as your dependent had2024 in the child not been stillborn? . . . . . . . . . . . . . . . . . . YesX NoX 22
23 (If you answered no, STOP HERE. You do not qualify for this credit.) 23
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25 For lines 1 through 5, enter the following information found on the Certificate of Birth Resulting in Stillbirth. If you have a Certificate of Birth 25
26 Resulting in Stillbirth for more than one child in 2024, complete a separate schedule for each child and include with your Form M1. 26
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28 1 Name of Parent 1 on the Certificate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 NAME PARENT1 28
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30 2 Name of Parent 2 on the Certificate (if listed) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 NAME PARENT2 30
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32 3 Date of delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 11223333 32
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34 State4 numberfile (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4. . 00000000000000 34
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36 5 Document control number (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5. 00000000000000 36
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38 6 Credit allowed per child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 2,000 38
39 Full-year residents: Include this amount on line 5 of Schedule M1REF and stop here. 39
40 7 Part-year residents and nonresidents: Multiply the amount on line 6 by line 30 40
41 of Schedule M1NR. Enter the result here on line 7 and on line 5 of Schedule M1REF. 41
42 If your Minnesota gross income is less than $14,575, see instructions; 42
43 enter the result from step 5 of the worksheet here: 12345 43
44 Enter the result from step 6 here and on line 5 of Schedule M1REF . . . . . . . . . . . . . . . . . . . . . . . . 7 12345678 44
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46 You must include this schedule with your Form M1. 46
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