Form 8962 - Premium Tax Credit (Ptc) - 2015

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8962
OMB No. 1545-0074
Premium Tax Credit (PTC)
2015
Form
Attach to Form 1040, 1040A, or 1040NR.
Attachment
Department of the Treasury
73
Information about Form 8962 and its separate instructions is at
Sequence No.
Internal Revenue Service
Name shown on your return
Your social security number
You cannot claim the PTC if your filing status is married filing separately unless you are eligible for an exception (see instructions). If you qualify, check the box.
Part I
Annual and Monthly Contribution Amount
1
Tax family size. Enter the number of exemptions from Form 1040 or Form 1040A, line 6d, or Form 1040NR, line 7d
1
2 a
Modified AGI. Enter your modified
b Enter the total of your dependents'
AGI (see instructions) .
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2a
modified AGI (see instructions)
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2b
3
3
Household income. Add the amounts on lines 2a and 2b
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4
Federal poverty line. Enter the federal poverty line amount from Table 1-1, 1-2, or 1-3 (see instructions). Check the
appropriate box for the federal poverty table used.
a
Alaska
b
Hawaii
c
Other 48 states and DC
4
5
5
Household income as a percentage of federal poverty line (see instructions)
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%
6
Did you enter 401% on line 5? (See instructions if you entered less than 100%.)
No. Continue to line 7.
Yes. You are not eligible to receive PTC. If advance payment of the PTC was made, see the instructions for
how to report your excess advance PTC repayment amount.
7
Applicable Figure. Using your line 5 percentage, locate your “applicable figure” on the table in the instructions
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7
Annual contribution amount. Multiply
b Monthly contribution amount. Divide line 8a by
8 a
8a
8b
line 3 by line 7 .
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12. Round to whole dollar amount
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Part II
Premium Tax Credit Claim and Reconciliation of Advance Payment of Premium Tax Credit
9
Are you allocating policy amounts with another taxpayer or do you want to use the alternative calculation for year of marriage (see instructions)?
Yes. Skip to Part IV, Shared Policy Allocation, or Part V, Alternative Calculation for Year of Marriage.
No. Continue to line 10.
10
See the instructions to determine if you can use line 11 or must complete lines 12 through 23.
Yes. Continue to line 11. Compute your annual PTC. Then skip lines 12–23
No. Continue to lines 12–23. Compute
and continue to line 24.
your monthly PTC and continue to line 24.
(d) Annual maximum
(b) Annual applicable
(a) Annual enrollment
(c) Annual
(e) Annual premium tax
(f) Annual advance
Annual
premium assistance
SLCSP premium
premiums (Form(s)
contribution amount
credit allowed
payment of PTC (Form
Calculation
(Form(s) 1095-A,
(subtract (c) from (b), if
(s) 1095-A, line 33C)
1095-A, line 33A)
(line 8a)
(smaller of (a) or (d))
line 33B)
zero or less, enter -0-)
11
Annual Totals
(c) Monthly
(a) Monthly enrollment
(b) Monthly applicable
(d) Monthly maximum
(f) Monthly advance
(e) Monthly premium tax
contribution amount
Monthly
premiums (Form(s)
SLCSP premium (Form
premium assistance
payment of PTC (Form(s)
(amount from line 8b
credit allowed
Calculation
1095-A, lines 21–32,
(s) 1095-A, lines 21–32,
(subtract (c) from (b), if
1095-A, lines 21–32,
or alternative marriage
(smaller of (a) or (d))
column A)
column B)
zero or less, enter -0-)
column C)
monthly contribution)
12
January
13
February
14
March
15
April
16
May
17
June
18
July
19
August
20
September
21
October
22
November
23
December
24
Total premium tax credit. Enter the amount from line 11(e) or add lines 12(e) through 23(e) and enter the total here
24
25
Advance payment of PTC. Enter the amount from line 11(f) or add lines 12(f) through 23(f) and enter the total here
25
26
Net premium tax credit. If line 24 is greater than line 25, subtract line 25 from line 24. Enter the difference here and on Form
1040, line 69; Form 1040A, line 45; or Form 1040NR, line 65. If you elected the alternative calculation for marriage, enter zero.
If line 24 equals line 25, enter zero. Stop here. If line 25 is greater than line 24, leave this line blank and continue to line 27
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26
Part III
Repayment of Excess Advance Payment of the Premium Tax Credit
27
27
Excess advance payment of PTC. If line 25 is greater than line 24, subtract line 24 from line 25. Enter the difference here
28
Repayment limitation (see instructions)
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28
Excess advance premium tax credit repayment. Enter the smaller of line 27 or line 28 here and on Form 1040, line
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46; Form 1040A, line 29; or Form 1040NR, line 44 .
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8962
For Paperwork Reduction Act Notice, see your tax return instructions.
Form
(2015)
Cat. No. 37784Z

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