Form 8885 - Health Coverage Tax Credit - 2015

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8885
Health Coverage Tax Credit
OMB No. 1545-0074
2015
Form
Attach to Form 1040, Form 1040NR, Form 1040-SS, or Form 1040-PR.
Department of the Treasury
Attachment
134
Information about Form 8885 and its instructions is at
Internal Revenue Service
Sequence No.
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.
!
Do not complete this form if you can be claimed as a dependent on someone else’s 2015 tax return.
CAUTION
Part I
Election To Take the Health Coverage Tax Credit
1
Check the box below for the first month in your tax year that you elect to take the Health Coverage Tax Credit. All of the
following statements must be true on the first day of that month. You must also check the box for each month after your
election month 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, including a qualified health plan
purchased through a Health Insurance Marketplace (also known as an Exchange), for which the premiums were paid by you
or through advance payment of the premium tax credit.
• 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.
Note: You cannot take the premium tax credit for any month you check a box below for the same coverage. Consider whether
the health coverage tax credit you elect will be more than any premium tax credit that you could take without the election. You
cannot change the election once it is made. See Participants in a Health Insurance Marketplace in the instructions.
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. Treat advance payments of the premium tax credit paid to the
Health Insurance Marketplace as paid by you. See the instructions before you complete line 2. Do
not include on line 2 any insurance premiums on coverage that was actually paid for with a
National Emergency Grant .
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2
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
4
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5
Health Coverage Tax Credit. Multiply the amount on line 4 by 72.5% (0.725). Enter the result
here and on Form 1040, line 73 (check box c); Form 1040NR, line 69 (check box c); Form
1040-SS, line 10; or Form 1040-PR, line 10 .
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8885
For Paperwork Reduction Act Notice, see your tax return instructions.
Form
(2015)
Cat. No. 34641D

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