Form 14116 Family Member Eligibility Form

Form 14116
(December 2009)

Department of the Treasury–Internal Revenue Service

HCTC Family Member Eligibility

OMB Number

Part I: Provide Information About You
Your name (first, middle initial, last, suffix)

Social security number

Your mailing address (street number)

(city, state, ZIP)

Telephone number

Gender: Male or Female

Your birth date (mm/dd/yyyy)

Part II: Provide Information About Your Family Member Who Was HCTC Eligible
Family member name (first, middle initial, last, suffix)

Family member birth date (mm/dd/yyyy)

Family member social security number

My family member is (check one):
A Trade Adjustment Assistance (TAA),
Alternative TAA, or Reemployment TAA
recipient
A Pension Benefit Guaranty Corporation
(PBGC) payee

Part III: Qualifying Event
Check the box below next to the qualifying event:

Date of qualifying event (mm/dd/yyyy)

Death
Divorce

Part IV: Supporting Documentation
Please provide the HCTC program with one of the following supporting documents:

•
•

Final Divorce Decree
Death Certificate

Under penalties of perjury, I declare that the information furnished on this form with regard to myself and to any family member(s), and
any attachments to it, is true, correct, and complete. I understand that a knowing and willfully false statement on this form can result in
my disqualification from the monthly HCTC program. By signing, I also agree to allow the IRS to share my eligibility status and
payment information with my health plan.
Signature

Full Name (print)

Date:
PAPERWORK REDUCTION ACT NOTICE. This form is a draft intended for internal use only. We ask for the information on this form to carry out
the Internal Revenue laws of the United States. Your response is voluntary. You are not required to provide the information requested on a form
that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its
instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax
returns and return information are confidential, as required by code section 6103. The estimated average time to complete this form is 15 minutes.
If you have comments concerning the accuracy of this time estimate or suggestions for making this form simpler, we will be happy to hear from
you. You can write to the Tax Products Coordinating Committee, SE:W:CAR:MP:T:T:SP, 1111 Constitution Ave. NW, Washington, DC 20224.
PRIVACY ACT STATEMENT. The following information is provided to comply with the Privacy Act of 1974 (P.L.93-579). All information collected
on this form is required under the provisions of 31 U.S.C. 3322 and 31 CFR 210. This information will be used by the Treasury Department to
transmit payment data, by electronic means to vendor’s financial institution. Failure to provide the requested information may delay or prevent the
receipt of payments through the Automated Clearing House Payment System.

Catalog Number 54355G

Form 14116 (12-2009)