Fillable Form 8885 - Health Coverage Tax Credit

Form 8885 (2012)

Page

Required Documents

Non-group (individual) health plans. You must

include the information under All health plans and both of

You must provide verifiable proof that your health

the following documents.

insurance plan is qualified and that you paid the qualified

• A letter or other document from your former employer

health insurance premiums by attaching the documents

or your unemployment office that shows the date you left

listed below to your Form 8885.

your job.

All health plans. For all health plans you must include

• A document from your health plan that shows your first

both of the following documents.

date of coverage. Your first day of coverage in a non-

1. A copy of your health insurance bills or COBRA

group (individual) health plan must have been at least 30

payment coupons.* The bills must have:

days before you left your job.

a. Your name (or name of the policy holder),

Coverage through your spouse’s employer. You

b. The name of your health plan,

must include the information under All health plans and

the following documents.

c. Your monthly premium amount,

• Copies of paycheck stubs showing the health coverage

d. Dates of coverage, and

deductions for the qualified months.

e. Your health plan identification number(s).

• A letter or other statement from your spouse’s employer

*If your qualified health plan does not provide members

that states the employer contributed less than 50% of the

with an insurance bill or COBRA payment coupon, you

cost of the coverage.

must provide health plan enrollment documents or an

official letter from your health plan that has the required

E-filed return. If you e-file, you can attach a copy of

information listed under (1a) through (1e) earlier. If your

any required documents to an electronically filed return as

monthly premium includes amounts that do not count

a PDF, if your tax software supports it, or you must attach

towards the HCTC, such as dental or vision coverage or

those documents to Form 8453, U.S. Individual Income

coverage for family members who are not eligible for the

Tax Transmittal for an IRS e-file Return, and mail them to

HCTC, your documentation must also specify those

the Internal Revenue Service according to the instructions

ineligible amounts.

for that form.

Example 1. You are eligible to claim the HCTC for

2. Proof of payment such as:**

October and November. In October, you paid $500 of

a. Canceled checks (copy of front and back),

qualified health insurance premiums for yourself and $250

for your qualifying family members. In November, you

b. Bank statements,

paid $206.25 (27.5% of the $750 November premium) to

c. Credit card statements, or

“U.S. Treasury–HCTC” and received an advance payment

d. Money orders.

of $543.75 (72.5% of the $750 November premium). Form

1099-H shows the total advance of $543.75 in box 13.

**Your proof of payment must indicate the amount paid

You would include $750 on line 2 for the October

and to whom it was paid. If you do not have one of these

insurance payment. You would not include any part of the

types of proof of payment, contact your health plan for a

November insurance premium since you already received

record of your payment(s).

the advance (monthly) payment for this month. You must

COBRA coverage. You must include the information

attach copies of your health insurance bills and proofs of

under All health plans and one of the following

payment for October for you and your qualifying family

documents.

members totaling $750, along with any other required

1. A copy of your completed and signed COBRA

documents.

Election Letter. It may also be called a COBRA Enrollment

Example 2. You are eligible to claim the HCTC for

Form, Application Form, Enrollment Application for

March and April. You paid $500 of qualified health

Continuing Coverage, or Election Agreement.

insurance premiums in each month for yourself and $250

2. A letter from your former employer or COBRA

for your qualifying family members directly to your

administrator saying you have COBRA coverage. The

qualified health plan. The amount on Form 8885, line 2, is

letter must have:

$1,500 ($750 each for March and April). You did not

receive any HCTC advance (monthly) payments during

a. The COBRA coverage start and end dates,

2012. You would enter $1,087.50 (72.5% of your March

b. Name of the health plan,

and April premiums) on line 5. You must attach copies of

your health insurance bills and proofs of payment for

c. Your home address, and

March and April for you and your qualifying family

d. Covered family members, their dates of birth, their

members totaling $1,500 ($750 for each month), along

relationship to you, and their social security numbers.

with any other required documents.

3. A copy of “Notice of Rights to Continue Coverage.”

Form 8885 - Health Coverage Tax Credit - 2012 Page 6

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