Form 8885 Health Coverage Tax Credit

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I.R.S. SPECIFICATIONS

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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

8885

Department of the Treasury
Internal Revenue Service

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
©

2009

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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 2009 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 2009 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 (ATAA) recipient, reemployment trade
adjustment assistance (RTAA) recipient, or Pension Benefit Guaranty Corporation (PBGC) pension recipient.
● You were covered by a qualified health insurance plan for which you paid the premiums, or your portion of the premiums,
directly to your health plan (including months for which you paid premiums to “U.S. Treasury–HCTC”).
● You were not enrolled in Medicare Part A or enrolled in Medicare Part B.

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

● You were not enrolled in the Federal Employees Health Benefits Program (FEHBP) or eligible to receive benefits under
the U.S. military health system (TRICARE).
● You were not imprisoned under federal, state, or local authority.
● Your employer did not pay 50% or more of the cost of coverage.
● You did not receive a 65% COBRA Premium Reduction from your former employer or COBRA administrator.

Part II

January

February

March

April

May

June

July

August

September

October

November

December

Health Coverage Tax Credit
Column A
January – April

2

Enter in each column the amount paid for qualified health insurance
coverage for the months checked on line 1 that are included under the
heading for the column (see instructions on page 3). Do not include on line
2 any qualified health insurance premiums paid to “U.S. Treasury–HCTC”
or any insurance premiums on coverage that was actually paid for with a
National Emergency Grant. Also, do not include any advance (monthly)
payments from Form 1099-H, box 1

Column B
May – December

2

You must attach the required documents listed on pages
3 and 4 for any amounts included on line 2. If you do not
attach the required documents, your credit will be
CAUTION
disallowed.
3

4
5
6
7

Enter in each column the total amount of any Archer MSA or health savings
accounts distributions used to pay for qualified health insurance coverage
for the months checked on line 1 that are included under the heading for
the column
3
Subtract line 3 from line 2. If zero or less, enter -0-. If you entered -0- in
both columns, stop; you cannot take the credit
4
.65
5
Applicable percentage
Multiply the amount on line 4 in each column by the applicable percentage
6
shown on line 5 for that column
Health Coverage Tax Credit. If you received an advance payment for any month not checked
on line 1, see the instructions for line 7 on page 4. Otherwise, add the amounts on line 6. Enter
the result here and on Form 1040, line 70 (check box d); Form 1040NR, line 64 (check box d);
Form 1040-SS, line 9; or Form 1040-PR, line 9

For Paperwork Reduction Act Notice, see page 4.

Cat. No. 34641D

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Form

8885

(2009)