Form 8885 - Health Insurance Credit For Eligible Recipients 2002

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OMB No. 1545-1807
8885
Health Insurance Credit For Eligible Recipients
2002
Form
Attachment
Department of the Treasury
Attach to Form 1040 or Form 1040NR.
134
Sequence No.
Internal Revenue Service
Name of recipient (if both spouses are recipients, complete a separate form for each spouse)
Recipient’s social security number
Before you begin: See Definitions and Special Rules in the instructions.
Part I
Complete This Part To See if You Are Eligible To Take This Credit
1
On December 1, 2002, were you an eligible trade adjustment assistance (TAA) or alternative TAA recipient?
No.
Go to question 2.
Yes.
Skip question 2 and go to question 3.
2
On December 1, 2002, were you an eligible Pension Benefit Guaranty Corporation (PBGC) pension recipient?
No.
Stop; you cannot take this credit.
Yes.
Go to question 3.
3
Can you be claimed as a dependent on someone else’s 2002 tax return?
No.
Go to question 4.
Yes. Stop; you cannot take this credit.
4
On December 1, 2002, were you covered by a qualified health insurance plan for which you paid the premiums?
No.
Stop; you cannot take this credit.
Yes.
Go to question 5.
On December 1, 2002, were you covered by, or eligible for coverage under, any employer-sponsored health
5
plan?
No.
Go to question 6.
Yes. See instructions.
On December 1, 2002, were you covered by Medicare, Medicaid, or State Children’s Health Insurance Program
6
(SCHIP)?
No.
Go to question 7.
Yes.
Stop; you cannot take this credit.
On December 1, 2002, were you enrolled in the Federal Employees Health Benefits Program or eligible to receive
7
benefits under the U.S. military health system (TRICARE/CHAMPUS)?
No.
Go to question 8.
Yes.
Stop; you cannot take this credit.
8 On December 1, 2002, were you imprisoned under Federal, state, or local authority?
No.
Go to line 9.
Yes. Stop; you cannot take this credit.
Part II
Health Insurance Credit
9 Enter the amount you paid for qualified health insurance coverage for the month of
9
December 2002 (see instructions)
10
10 Archer MSA distributions used to pay amounts included on line 9
11
11 Subtract line 10 from line 9. If zero or less, stop; you cannot take this credit
12 Health insurance credit. Multiply line 11 by 65% (.65) and enter the result. Also
include on Form 1040, line 68, or Form 1040NR, line 63, and check box c on that
line
12
8885
For Paperwork Reduction Act Notice, see back of form.
Cat. No. 34641D
Form
(2002)

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