Instructions For Form 8885 - Health Coverage Tax Credit - 2017 Page 6
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6be called a COBRA Enrollment Form,
employer contributed less than 50% of the
showing an advance payment of $543.75
Application Form, Enrollment Application
cost of the coverage (TAA recipients and
for your July coverage. You would include
for Continuing Coverage, or Election
PBGC payees) or made no contributions
the $750 you paid for your June coverage
Agreement.
to the cost of coverage (ATAA and RTAA
on line 2. You wouldn’t include any part of
recipients).
the July coverage premium on line 2
2. A letter from your former employer
because you already received the benefit
or COBRA administrator saying you have
E-filed return. If you e-file, you can
of the advance monthly payment program
COBRA coverage. The letter must have:
attach a copy of any required documents
for July. You must attach copies of your
a. The COBRA coverage start and
to an electronically filed return as a PDF if
health insurance bills and proofs of
end dates;
your tax software supports it, or you must
payment for the June coverage for you
attach those documents to Form 8453,
b. Name of the health plan;
and your qualifying family members
U.S. Individual Income Tax Transmittal for
totaling $750, along with any other
c. Your home address; and
an IRS e-file Return, and mail them to the
required documents. You don’t need to
d. Covered family members, their
IRS according to the instructions for that
attach documents for your July coverage.
dates of birth, their relationship to you, and
form.
Example 2. You checked March and
their social security numbers.
Example 1. You checked June and
April on line 1. Your insurance coverage
3. A copy of “Notice of Rights to
July on line 1. Your insurance coverage for
for each month costs $750 ($500 for you
Continue Coverage.”
each month costs $750 ($500 for you and
and $250 for your qualifying family
$250 for your qualifying family members).
Coverage through your spouse’s
members). You paid $750 directly to your
You paid $750 directly to your health plan
employer. You must include the
health plan for each month. You would
for your June coverage. You then paid
information under
All health plans
and the
include $1,500 on line 2 for the March and
$206.25 (27.5% of the $750 premium) for
following documents.
April coverage. You must attach copies of
your July coverage as part of the advance
Copies of paycheck stubs showing the
your health insurance bills and proofs of
monthly payment program. Your health
health coverage deductions for each
payment for the March and April coverage
plan administrator received an advance
month you are claiming the credit on
for you and your qualifying family
payment of $543.75 (72.5% of the $750
line 2.
members totaling $1,500 ($750 for each
premium) from the IRS for your July
A letter or other statement from your
month), along with any other required
coverage. You received a Form 1099-H
spouse’s employer that states the
documents.
Instructions for Form 8885 (2017)
-6-
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