Form 14095 The Health Coverage Tax Credit (HCTC) Reimbursement Requ

Department of the Treasury–Internal Revenue Service

Form 14095
(Rev. February 2010)

The Health Coverage Tax Credit (HCTC)
Reimbursement Request

OMB No. 1545-2152

Part 1: Provide information about yourself
Name (first, middle initial, last, suffix)

Social Security Number

Mailing Address (street number)

City, State, Zip

Primary Telephone Number (include area code)

Part 2: Request reimbursement
Check the box next to each month of this calendar year for which you are requesting reimbursement. For each month checked, you
certify that you 1) met all eligibility requirements for the HCTC and 2) that you made payments directly to a qualified health plan for
that month.
January

February

March

April

May

June

July

August

September

October

November

December

In the tables below, enter the information requested for EACH MONTH checked above. If you are requesting reimbursement for
more than two months, copy this form and complete Part 2 for those additional months.
Month and year for which you are requesting reimbursement.

1

Total monthly premium amount you paid directly to your qualified health plan
(for yourself and your family members).

2

Amount you paid for separate dental or vision benefits. These benefits do not
qualify for the HCTC.

3

Amount you paid for family members who are not qualified for the HCTC, including
yourself if you are enrolled in Medicare.

4

Amount of National Emergency Grant (NEG) payments received.

Month and year for which you are requesting reimbursement.

1

Total monthly premium amount you paid directly to your qualified health plan
(for yourself and your family members).

2

Amount you paid for separate dental or vision benefits. These benefits do not
qualify for the HCTC.

3

Amount you paid for family members who are not qualified for the HCTC, including
yourself if you are enrolled in Medicare.

4

Amount of National Emergency Grant (NEG) payments received.

Month

Year

Month

Year

Part 3: Provide information about your qualified health insurance
Check the box below that applies to the months for which you’ve requested reimbursement:
I certify that the health plan for this reimbursement request is the same as the qualified health plan listed on my Monthly HCTC
Registration.
The health plan for this reimbursement request is different from the qualified health plan listed on my Monthly HCTC
Registration. If so, complete Part 5 of the HCTC Registration Update Form (13704) and attach it to this form. This form can
be obtained by going to www.irs.gov/hctc.

Catalog Number 53672K

Form 14095 (Rev. 2-2010)

Part 4: Gather supporting documents
Include copies of 1) health insurance bills or payment coupons and 2) proof of payment for the months in Part 2 of this form.
1) Your health insurance bills or payment coupons must show the following information:

•
•
•
•
•

Your name (or name of the policy holder)
Name of your health plan
Your monthly premium amount
Dates of coverage
Your health plan identification number

Note: If your qualified health plan does not provide members with an insurance bill or COBRA payment coupon, you must provide
health plan enrollment documents or an official letter from your health plan that has the required information listed in the bullets above.
2) Acceptable proof of payment includes:

•
•
•
•

Cancelled checks (copy of front and back)
Bank statements
Credit card statements
Money order receipts

Note: Your proof of payment must indicate the amount paid and to whom it was paid. If you do not have one of these proofs of
payment, contact your health plan for a record of your payment(s).

Part 5: 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)

For Paperwork Reduction Act Notice, see instructions.

Catalog Number 53672K

Date

Form 14095 (Rev. 2-2010)