Form 14117 HCTC Family Member Registration

Form 14117
(January 2010)

Department of the Treasury–Internal Revenue Service

OMB Number

HCTC Family Member Registration

1545-2162

Family members of HCTC eligible individuals may receive the HCTC for up to 24 months following the eligible individual’s Medicare
enrollment. If you are an HCTC eligible individual, complete this form to register your family members—or to continue their
enrollment—in the monthly Health Coverage Tax Credit (HCTC) Program as you enroll in Medicare. Please note that the American
Recovery and Reinvestment Act which makes this possible ends December 31, 2010 unless re-authorized by Congress.

Instructions:
1.
2.
3.
4.

Print or type your responses.
Sign and date this form.
Keep a copy of this completed form and all required supporting documents for your personal records.
DO NOT SEND PAYMENT WITH THIS FORM. Mail the completed form and supporting documents to:
HCTC Processing Center
P.O. Box 760189
San Antonio, TX 78245

Part 1: Provide information about you
Name (first, middle initial, last, suffix)
Date of Birth (mm/dd/yyyy)

Gender
Male
Female
Social Security Number (SSN)

Mailing Address (street number)

City, State, ZIP

Primary Telephone Number (include area code)

Date eligible for Medicare

Part 2: Provide information about your family member(s)
If you have more than one eligible family member, make a copy of this page and complete it for any additional family members.
Name (first, middle initial, last, suffix)

Date of Birth (mm/dd/yyyy)

Relationship to you:
Spouse
Child

Social Security Number (SSN)
Other

Would you like for this individual to have authorized access to your account?

Yes

No

If yes, choose a Personal Identification Number (PIN). The PIN must be a five-digit number
For more information about authorized individuals, please refer to your HCTC Program Kit.

Part 3: Confirm that the following statements are true
Check all boxes that apply. I certify that I am:
Enrolled in Medicare, and I am completing this form to register my HCTC-qualified family members only.
A Trade Adjustment Assistance (TAA), Alternative TAA, or Re-employment TAA recipient, or
Pension Benefit Guaranty Corporation (PBGC) payee and am 55 years old or older.
Not claimed as a dependent on anyone’s tax return.
Check all boxes that apply. I certify that my family member(s) and I:
Cannot receive health coverage through the U.S. military health system (TRICARE).
Are not enrolled in the Children’s Health Insurance Program (CHIP) or the Federal Employees
Health Benefits Program (FEHBP).
Are not in prison.
Are not receiving a 65% COBRA Premium Reduction through a former employer or COBRA administration.
Are not covered by any health insurance plan where a former employer, or spouse’s employer, pays 50% or
more of the premiums.
Check all boxes that apply. I certify that my family member(s):
Is covered by a qualified health insurance plan.
Is not enrolled in Medicare Part A, B, or C.
Is my spouse or is claimed as a dependent(s) on my tax return.

Catalog Number 54361K

Form 14117 (1-2010)

Part 4: Provide health plan information about your family member(s)
Fill out the information below for you and your family member(s). If any of your family members have a separate health plan,
make a copy of this page and complete it for each individual.
Check the box that applies:
Although eligible for Medicare, I am covered by the insurance plan listed below.
I am not covered by the plan listed below.
Please
complete
this section.

Name of health plan

Type of coverage:

COBRA

Non-group/individual
Health plan ID number

VEBA

Member ID

Policyholder’s name (first, middle initial, last, suffix)

State-qualified

(Only certain VEBAs qualify for the HCTC.
Please see the HCTC Program Kit for more details.)

Group ID

Policy or Plan ID

Policyholder’s SSN

Total monthly premium

Total number of people (you and any family members) on this policy
Number of family members on this policy who are not eligible for the HCTC
Monthly premium amount for family members who are not eligible for the HCTC
Extra monthly premium amount that covers dental or vision plans
Complete this
section only if
you have
COBRA
coverage*.

Your former employer

Former employer’s telephone number (include area code)

Start date for COBRA coverage (mm/dd/yy)

End date for COBRA coverage (mm/dd/yy)
Check here if Lifetime Benefit

Complete this
section only if
you have nongroup/individual
coverage*.

Employer that made you eligible for PBGC or TAA benefits

Employer’s telephone number (include area code)

Your last paid day of work for that employer

Start date of non-group/individual insurance

*If you have this type of health plan, additional supporting documents are required. Visit www.irs.gov, and search for “HCTC.” Click the link for “The Monthly HCTC.”

Part 5: Gather supporting documents
Please send us:
A copy of your family’s health insurance bill dated within the last 60 days. Make sure it has all of the following information:
• Your name
• Name and phone number of your health plan or administrator, the address for mailing your payments, health plan
identification number(s)
• Monthly premium amount, monthly premium due date, and dates of coverage
If necessary, the bill may need to show the following:

•
•

Dollar amounts for family members who are not eligible for the HCTC
Separate dollar amounts that do not count toward the HCTC (such as dental or vision coverage)

Note: Usually your health insurance bill will have all this information on it. If it doesn’t, you must give us a letter from your health plan with this information on it. If you
have COBRA or non-group individual coverage, you will need to provide additional supporting documents that can be found on www.irs.gov; search for “HCTC.”

If you have any questions about this form, please contact the HCTC Customer Contact Center toll-free at 1-866-628-HCTC (4282). If you have
a hearing impairment, call 1-866-626-4282 (TTY)

Part 6: Sign and date this form
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. 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 54361K

Form 14117 (1-2010)