8885
Health Coverage Tax Credit
OMB No. 1545-0074
2012
Form
Attach to Form 1040, Form 1040NR, Form 1040-SS, or Form 1040-PR
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Department of the Treasury
Attachment
134
Information about Form 8885 and its instructions is at
Internal Revenue Service
Sequence No.
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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.
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Do not complete this form if you can be claimed as a dependent on someone else’s 2012 tax return.
CAUTION
Part I
Complete This Part To See if You Are Eligible To Take This Credit
1
Check the boxes below for each month in 2012 that all of the following statements were true on the first day of that month.
• You were an eligible trade adjustment assistance (TAA) recipient, alternative TAA (ATAA) recipient, reemployment TAA (RTAA)
recipient, or Pension Benefit Guaranty Corporation (PBGC) pension payee; or you were a qualified family member of an
individual who fell under one of the categories listed above when he or she passed away or with whom you finalized
a divorce.
• You and/or your family member(s) were covered by a qualified health insurance plan for which you paid the entire premiums,
or your portion of the premiums, directly to your health plan or to “U.S. Treasury–HCTC.”
• You were not enrolled in Medicare Part A, B, or C, or you were enrolled in Medicare but your family member(s) qualified for
the HCTC.
• You were not enrolled in Medicaid or the Children’s Health Insurance Program (CHIP).
• You were not enrolled in the Federal Employees Health Benefits Program (FEHBP) or eligible to receive benefits under the
U.S. military health system (TRICARE).
• You were not imprisoned under federal, state, or local authority.
• Your employer did not pay 50% or more of the cost of coverage.
• You did not receive a 65% COBRA premium reduction from your former employer or COBRA administrator.
January
February
March
April
May
June
July
August
September
October
November
December
Part II
Health Coverage Tax Credit
2
Enter the total amount paid directly to your health plan for qualified health insurance coverage for
the months checked on line 1 (see instructions). Do not include on line 2 any qualified health
insurance premiums paid to “U.S. Treasury–HCTC” or any insurance premiums on coverage that
was actually paid for with a National Emergency Grant. Also, do not include any advance
(monthly) payments or reimbursement credits you received as shown on Form 1099-H, box 1 .
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2
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You must attach the required documents listed in the instructions for any amounts
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included on line 2. If you do not attach the required documents, your credit will be
disallowed.
CAUTION
3
Enter the total amount of any Archer MSA or health savings accounts distributions used to pay for
qualified health insurance coverage for the months checked on line 1 .
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3
4
Subtract line 3 from line 2. If zero or less, stop; you cannot take the credit
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4
Health Coverage Tax Credit. If you received an advance (monthly) payment in any month not
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checked on line 1, see the instructions for line 5 for more details. Otherwise, multiply the amount
on line 4 by 72.5% (.725). Enter the result here and on Form 1040, line 71 (check box d); Form
1040NR, line 67 (check box d); Form 1040-SS, line 9; or Form 1040-PR, line 9 .
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8885
For Paperwork Reduction Act Notice, see your tax return instructions.
Form
(2012)
Cat. No. 34641D