Instructions For Form 14095 (February 2010) - Department Of The Treasury printable pdf download

Instructions for Form 14095

Department of the Treasury

Internal Revenue Service

(February 2010)

The Health Coverage Tax Credit (HCTC) Reimbursement Request

•

Paying more than 50% of your health insurance

General Instructions

premium. (i.e., an employer did not pay 50% or

more of your premium).

Please follow the instructions below to complete Form 14095.

Print or type your responses and complete each part of this

•

Not enrolled in Medicare Part A, B, or C. OR you

form. If you have any questions, please contact the HCTC

were enrolled, but are only claiming premiums for

Customer Contact Center toll-free at 1-866-628-HCTC (4282).

qualified family members.

If you have a hearing impairment, call 1-866-626-4282.

•

Not enrolled in Medicaid or the Children’s Health

Insurance Program (CHIP).

You can request reimbursement for premiums you paid during

this calendar year for qualified coverage while you were

•

Not enrolled in the Federal Employees Health

eligible and enrolling in the monthly HCTC Program. We will

Benefits Program (FEHBP) or the U.S. military

post this reimbursement as a credit to your monthly HCTC

health system (TRICARE).

account. You can keep the credit on your HCTC account to

use for future payments, or you may request to have it

•

Not imprisoned under federal, state, or local

returned to you once the HCTC Program has processed it.

authority.

•

Not receiving the 65% COBRA Premium Reduction

Purpose of Form

through a former employer or COBRA

administrator.

Use this form to request an HCTC reimbursement credit for

premiums paid directly to your qualified health plan while you

were eligible and enrolling in the monthly HCTC Program.

2) Reimbursement Period:

You must be a monthly HCTC participant, or have an HCTC

•

For PBGC payees- You can request reimbursement

registration in process, for us to consider your request.

beginning with the month following the date printed

on your HCTC Eligibility Certificate, which was sent

Complete Form 14095 as Follows:

with your original Program Kit.

Part 1. Complete each line; all the information is required.

•

For TAA, ATAA, and RTAA recipients- You can

request reimbursement beginning with the month of

Part 2. Check the box next to each month of the calendar

the date printed on your HCTC Eligibility Certificate,

year for which you are requesting reimbursement.

which was sent with your original Program Kit.

For each month you are requesting reimbursement,

•

confirm that you: 1) met all eligibility requirements

For qualified family members- family members

who are applying for the HCTC after the PBGC

for the HCTC and 2) made payments directly to a

qualified health plan. Then fill out the table for each

payee or TAA recipient has enrolled in Medicare,

month for which you are requesting reimbursement

finalized a divorce, or passed away can request

reimbursement starting with the month in which

for. If you are requesting reimbursement for more

than two months, copy the form and complete Part 2

the event took place.

for the additional months.

Note: If you were eligible for the HCTC and paid for qualified

Note: If you would like to calculate the exact amount you

coverage prior to the date on your HCTC Eligibility Certificate,

will be reimbursed for each month, please see the Monthly

you may be able to receive the HCTC when you file your

Reimbursement Calculation instructions on the next page.*

federal tax return using IRS Form 8885. You also can use

Form 8885 to receive the HCTC for previous calendar years.

1) Eligibility Requirements for the HCTC:

You are eligible for the HCTC for the months in which

Part 3. Complete this section to confirm your qualified health

you or your family member(s) were:

insurance. Check the box if your qualified health plan

•

An eligible Trade Adjustment Assistance (TAA),

for this reimbursement request is the same plan used

Alternative TAA (ATAA), or Reemployment TAA

for your HCTC registration. If it is different, you must

(RTAA) recipient; a Pension Benefit Guaranty

attach another form, the HCTC Registration Update

Corporation (PBGC) payee and 55 years old or

Form. Please complete Part 5 of the HCTC

older; OR a qualified family member eligible for

Registration Update Form and attach it to this form.

the HCTC due to the death of or divorce from a

Part 5 is required to provide information about the

PBGC payee or TAA recipient.

coverage for which you are requesting reimbursement.

•

Additional supporting documents will be required. The

Covered by a qualified health plan for which you

HCTC Registration Update Form is available online;

paid the premiums, or your portion of the

visit

premiums, directly to your health plan.

14095

Instructions for Form

(2-2010)

Catalog Number 54402U

Department of the Treasury — Internal Revenue Service

Instructions For Form 14095 (February 2010) - Department Of The Treasury

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