Form 13562 Health Coverage Tax Credit (HCTC) General Registration I

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Department of the Treasury – Internal Revenue Service
Form 13562
(Rev. April 2007)

HEALTH COVERAGE TAX CREDIT (HCTC)
GENERAL REGISTRATION INFORMATION FORM
(See Instructions on Page 2)

The HCTC General Registration Information Form is a standard form used by the HCTC Program to collect required
information in addition to the U.S. Department of the Treasury’s ACH Vendor/Miscellaneous Payment Enrollment Form.
( * ) Denotes a required field

( #x. ) Indicates corresponding explanations on prior page

1.* ADDITIONAL COMPANY INFORMATION
*1a. LEGAL NAME:
*1b. LEGAL ADDRESS:

*1c. EIN/TIN (ASSOCIATED WITH LEGAL NAME):

*1d. INVOICE REMIT TO ADDRESS:

ATTN:
1e. HPA CONTACT NAME:

1f. HPA CONTACT MAILING ADDRESS:

HPA CONTACT TELEPHONE NUMBER:

HPA CONTACT FAX NUMBER:

HPA CONTACT E-MAIL:

*2. PAYMENT REMITTANCE ADVICE CONTACT
NAME:
ADDRESS:

TELEPHONE NUMBER:

E-MAIL:

FAX NUMBER:

*3. SIGN-OFF BY AUTHORIZED OFFICIAL
SIGNATURE:

PRINT/TYPE NAME:

DATE:

TITLE:

Catalog Number 38305W

Form 13562 Page 1 (Rev. 4-2007)

Instructions for Completing Health Coverage Tax Credit (HCTC)
General Registration Information Form
The HCTC General Registration Information Form is a standard form used by the HCTC Program to collect
required information in addition to the Treasury Department’s ACH Vendor/Miscellaneous Enrollment Form.
1. ADDITIONAL COMPANY INFORMATION SECTION – Print or type the name and address of the enrolling
company, EIN/TIN number, invoice remit to address, and contact information for the HPA contact.
a. Legal Name: Must be the same as the name indicated on the Payee/Company Information field of the
ACH Vendor/Miscellaneous Payment Enrollment Form.
b. Legal Address: Must be the same as the address indicated on the Payee/Company Information field of the
ACH Vendor/Miscellaneous Payment Enrollment Form.
c. EIN/TIN (Employer Identification Number/Taxpayer Identification Number): The EIN/TIN provided must be
the EIN/TIN associated with the Legal Name of the business. The information provided in this field should
also be the same information provided on the Automated Clearing House (ACH) Form in the “SSN or
Taxpayer ID Number” field.
d. Invoice Remit To Address: The invoice remit to address appears on invoices and is associated with the
bank account holder. If there are multiple remit to addresses, please provide those on a separate sheet.
e. HPA (Health Plan Administrator) Contact Name: The company representative whom the IRS HCTC
Finance and Accounting representative should work with on HCTC related matters.
f.

HPA Contact Mailing Address: The mailing address for the individual identified in field (e). The HPA
Contact Mailing Address could also be the same as the Legal Address in field (b). If this is the case,
please indicate as such.

2. PAYMENT REMITTANCE ADVICE CONTACT SECTION – Should contain the contact information for
the person who will receive the payment remittance advice. If any of the information is the same as the
HPA Contact, please indicate as such.
3. SIGN-OFF BY AUTHORIZED OFFICIAL SECTION – Signed by the individual who is authorized by their
company to provide the information requested on the form. Print or type the name of the individual, title, and
the current date.

Fax the HCTC General Registration Information Form to:
HCTC Finance and Accounting Center
Attn: Systems Control Team
Fax Number: 1-800-675-9602

Catalog Number 38305W

Form 13562 Page 2 (Rev. 4-2007)