8839 Qualified Adoption Expenses

Caution: DRAFT FORM
This is an advance proof copy of an IRS tax form.
It is subject to change and OMB approval before it
is officially released. You can check the scheduled
release date on our web site (www.irs.gov).
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Version B

4

I.R.S. SPECIFICATIONS

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TO BE REMOVED BEFORE PRINTING

INSTRUCTIONS TO PRINTERS
FORM 8885, PAGE 1 of 4
MARGINS: TOP 13 mm (1⁄ 2 "), CENTER SIDES.
PRINTS: HEAD TO HEAD
PAPER: WHITE WRITING, SUB. 20.
INK: BLACK
FLAT SIZE: 203 mm (81⁄ 2 ") 3 279 mm (11")
PERFORATE: ON FOLD

Date

8885

Date

Signature

O.K. to print

DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Form

Action

Revised proofs
requested

OMB No. 1545-0074

Health Coverage Tax Credit

Department of the Treasury
Internal Revenue Service

©

2006

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Attachment
Sequence No.

Attach to Form 1040, Form 1040NR, Form 1040-SS, or Form 1040-PR.

Name of recipient (if both spouses are recipients, complete a separate form for each spouse)

134

Recipient’s social security number

Before you begin: See Definitions and Special Rules that begin on page 2.

Do not complete this form if you can be claimed as a dependent on someone else’s 2006 tax return.
CAUTION

Part I
1

Complete This Part To See if You Are Eligible To Take This Credit

Check the boxes below for each month in 2006 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 recipient, or Pension Benefit Guaranty
Corporation (PBGC) pension recipient.
● You were covered by a qualified health insurance plan for which you paid the premiums.
● You were not entitled to Medicare Part A or enrolled in Medicare Part B.

● You were not enrolled in Medicaid or State Children’s Health Insurance Program (SCHIP).

● You were not enrolled in the Federal Employees Health Benefits Program or eligible to receive benefits under the U.S.
military health system (TRICARE).
● You were not imprisoned under federal, state, or local authority.
● You were not covered by, or eligible for coverage under, any employer-sponsored health insurance plan (including any
employer-sponsored health insurance plan of your spouse) (see the instructions for line 1 that begin on page 3).

Part II
2

January

February

March

April

May

June

July

August

September

October

November

December

Health Coverage Tax Credit

Amount paid for qualified health insurance coverage for all months checked on line 1 (see
instructions on page 3). Do not include on line 2 any qualified health insurance premiums
paid to “U.S. Treasury—HCTC.” Also, do not include any advance payments from Form
1099-H, box 1

2

Caution. You must attach the required documents listed on
page 4 for any amounts included on line 2 (see instructions on
page 3). If you do not attach the required documents, your
credit will be disallowed.
3

Enter the total amount of any (a) Archer MSA and health savings account distributions used
to pay for qualified health insurance coverage for all months checked on line 1 and (b) National
Emergency Grants you received for health insurance in 2006

3

4

Subtract line 3 from line 2. If zero or less, stop; you cannot take the credit

4

5

Health coverage tax credit. Multiply line 4 by 65% (.65). Enter the result here and on Form
1040, line 70; Form 1040NR, line 64 (ensuring you check box c on either of those lines); Form
1040-SS, line 9; or Form 1040-PR, line 9

5

For Paperwork Reduction Act Notice, see page 4.

Cat. No. 34641D

Form

8885

(2006)