Form 14095 - The Health Coverage Tax Credit (Hctc) Reimbursement Request Form
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1
2Department of the Treasury–Internal Revenue Service
14095
Form
The Health Coverage Tax Credit (HCTC)
OMB No. 1545-2152
(Rev. February 2010)
Reimbursement Request
Part 1: Provide information about yourself
Name (first, middle initial, last, suffix)
Social Security Number
Mailing Address (street number)
City, State, Zip
Primary Telephone Number (include area code)
Part 2: Request reimbursement
Check the box next to each month of this calendar year for which you are requesting reimbursement. For each month checked, you
certify that you 1) met all eligibility requirements for the HCTC and 2) that you made payments directly to a qualified health plan for
that month.
January
February
March
April
May
June
July
August
September
October
November
December
In the tables below, enter the information requested for EACH MONTH checked above. If you are requesting reimbursement for
more than two months, copy this form and complete Part 2 for those additional months.
Month
Year
Month and year for which you are requesting reimbursement.
Total monthly premium amount you paid directly to your qualified health plan
1
(for yourself and your family members).
Amount you paid for separate dental or vision benefits. These benefits do not
2
qualify for the HCTC.
Amount you paid for family members who are not qualified for the HCTC, including
3
yourself if you are enrolled in Medicare.
4
Amount of National Emergency Grant (NEG) payments received.
Month
Year
Month and year for which you are requesting reimbursement.
Total monthly premium amount you paid directly to your qualified health plan
1
(for yourself and your family members).
Amount you paid for separate dental or vision benefits. These benefits do not
2
qualify for the HCTC.
Amount you paid for family members who are not qualified for the HCTC, including
3
yourself if you are enrolled in Medicare.
4
Amount of National Emergency Grant (NEG) payments received.
Part 3: Provide information about your qualified health insurance
Check the box below that applies to the months for which you’ve requested reimbursement:
I certify that the health plan for this reimbursement request is the same as the qualified health plan listed on my Monthly HCTC
Registration.
The health plan for this reimbursement request is different from the qualified health plan listed on my Monthly HCTC
Registration. If so, complete Part 5 of the HCTC Registration Update Form (13704) and attach it to this form. This form can
be obtained by going to
14095
Catalog Number 53672K
Form
(Rev. 2-2010)
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