Form 1099-H - Health Coverage Tax Credit (Hctc) Advance Payments

Instructions for Recipient

Note. This statement reflects the tax credit that you and any qualified

family members received in 2012 through the monthly HCTC Program.

Recipient's identification number. For your protection, this form may

It does not reflect payments you made to the HCTC Program (“U.S.

show only the last four digits of your social security number (SSN),

Treasury – HCTC”) which were forwarded to your health plan by the

individual taxpayer identification number (ITIN), or adoption taxpayer

HCTC Program.

identification number (ATIN). However, the issuer has reported your

Any HCTC amount listed on this statement cannot be claimed on

complete identification number to the IRS and, where applicable, to

your federal income tax return. Claiming this amount means you

state and/or local governments.

would receive the credit twice. If you receive the credit for amounts you

This statement is provided to you because the HCTC Program made

are not entitled to, you will be required to repay the IRS. Only payments

monthly payment(s) to your health plan to cover a portion of your health

you paid directly to your health plan can be claimed on your federal

insurance costs in 2012. These payments are referred to on this

income tax return. This means any amounts for which you received an

statement as advance payments. These advance payments are shown

advance payment or reimbursement credit cannot be claimed on your

in Boxes 1 through 14 as follows:

tax return (any reimbursement credits will be reflected on this form). For

Box 1. Shows the total amount of HCTC advance payments that were

example, if you paid $100 to your health plan and received a $72.50

made on your behalf for the entire year, as well as the total amount of

advance payment or reimbursement credit, you cannot claim the same

reimbursement credits paid to you prior to your HCTC enrollment.

$100 on your tax return. Similarly, if you sent $27.50 to the HCTC

Program to cover your portion of your monthly $100 health plan

Box 2. Shows the total number of months HCTC advance payments or

premium, you cannot claim that payment on your tax return because

reimbursement credits were made on your behalf.

you already received the $72.50 tax credit. See IRS Form 8885 for more

Boxes 3 through 14. Shows the total amount of any HCTC advance

information on these requirements.

payments or reimbursement credits that were made on your behalf

Need help? If you have any questions regarding this statement, call the

each month. The sum of these amounts equals the amount shown in

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

Box 1.

you have a hearing impairment, call 1-866-626-4282 (TTY). For general

information about the HCTC, visit IRS.gov (keyword/Search: HCTC).

Form 1099-H - Health Coverage Tax Credit (Hctc) Advance Payments - 2012 Page 6

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