Form 8962 - Premium Tax Credit (Ptc) - 2016 Page 2
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Form 8962 (2016)
Page
Part IV
Allocation of Policy Amounts
Complete the following information for up to four shared policy allocations. See instructions for allocation details.
Allocation 1
(a) Policy Number (Form 1095-A, line 2)
(b) SSN of other taxpayer
(c) Allocation start month
(d) Allocation stop month
30
(g) Advance Payment of the PTC
Allocation percentage
(e) Premium Percentage
(f) SLCSP Percentage
Percentage
applied to monthly
amounts
Allocation 2
(a) Policy Number (Form 1095-A, line 2)
(b) SSN of other taxpayer
(c) Allocation start month
(d) Allocation stop month
31
(g) Advance Payment of the PTC
Allocation percentage
(e) Premium Percentage
(f) SLCSP Percentage
Percentage
applied to monthly
amounts
Allocation 3
(a) Policy Number (Form 1095-A, line 2)
(b) SSN of other taxpayer
(c) Allocation start month
(d) Allocation stop month
32
(g) Advance Payment of the PTC
Allocation percentage
(e) Premium Percentage
(f) SLCSP Percentage
Percentage
applied to monthly
amounts
Allocation 4
(a) Policy Number (Form 1095-A, line 2)
(b) SSN of other taxpayer
(c) Allocation start month
(d) Allocation stop month
33
(g) Advance Payment of the PTC
Allocation percentage
(e) Premium Percentage
(f) SLCSP Percentage
Percentage
applied to monthly
amounts
34
Have you completed all policy amount allocations?
Yes. Multiply the amounts on Form 1095-A by the allocation percentages entered by policy. Add all allocated policy amounts and non-
allocated policy amounts from Forms 1095-A, if any, to compute a combined total for each month. Enter the combined total for each month on
lines 12–23, columns (a), (b), and (f). Compute the amounts for lines 12–23, columns (c)–(e), and continue to line 24.
No. See the instructions to report additional policy amount allocations.
Part V
Alternative Calculation for Year of Marriage
Complete line(s) 35 and/or 36 to elect the alternative calculation for year of marriage. For eligibility to make the election, see the instructions for line 9.
To complete line(s) 35 and/or 36 and compute the amounts for lines 12–23, see the instructions for this Part V.
(a) Alternative family size (b) Alternative monthly
(c) Alternative start month
(d) Alternative stop month
Alternative entries
35
contribution amount
for your SSN
(a) Alternative family size (b) Alternative monthly
(c) Alternative start month
(d) Alternative stop month
Alternative entries
36
contribution amount
for your spouse's
SSN
8962
Form
(2016)
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