Form 14950 - Premium Tax Credit Verification - 2014
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114950
Department of the Treasury–Internal Revenue Service
Form
Premium Tax Credit Verification
(Rev. October 2014)
Name of Taxpayer
Taxpayer Identification Number
Tax Period Ending
We need to verify if you are eligible to claim the Premium Tax Credit (PTC) shown on your return. To show that you are
eligible for the PTC, you will need to send all of the applicable documents from the list below. If you did not retain the
necessary records, we suggest you contact the health insurance marketplace, insurance providers, plan administrators,
and/or financial institutions for the information.
What You Should Send Us
• Form 8962, Premium Tax Credit, is required to reconcile any advance payments of the premium tax credit. If you
didn’t include Form 8962 with your tax return, send us a completed copy.
• If you included Form 8962, Premium Tax Credit, with your tax return, review it for accuracy. If you determine Form
8962 was not completed accurately, send us an updated copy.
• Form 1095-A, Health Insurance Marketplace Statement. If you didn’t receive Form 1095-A or you think it is incorrect,
we suggest you contact the Health Insurance Marketplace to obtain a new or corrected copy.
• Records showing the names of the individuals that you are claiming for the Premium Tax Credit. These records can
include copies of insurance enrollment forms, invoices, or statements from your insurance providers.
• Information to support the entries made in Part 4 of Form 8962, Premium Tax Credit, regarding your allocation of the
premium tax credit. This information includes:
(1) Allocated Policy Number
(2) Allocation SSN
(3) Allocation Percentages
(4) Allocation Start/Stop months
• Information to support the entries made in Part 5 of Form 8962, Premium Tax Credit, regarding the Alternative
Calculation for Year of Marriage. This information includes:
(1) Alternative Family Size
(2) Alternative Start/Stop months
(3) Your date of marriage
• Proof that you paid health insurance premiums. Acceptable documentation includes copies of both sides of cancelled
checks, paid receipts, certificates of group health plan coverage, credit card statements, or bank records showing
direct debit of the payments.
14950
Form
(Rev. 10-2014)
Catalog Number 65540P
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