Form 13441-EZ Monthly HCTC (Health Coverage Tax Credit) Group Registra

Department of the Treasury
Internal Revenue Service

Instructions for Form 13441-EZ

(Rev. June 2011)

Monthly Health Coverage Tax Credit (HCTC) Group Registration

General Instructions
Please follow the instructions below to complete Form
13441-EZ. Print or type your responses. If you have any
questions, 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).

Purpose of Form
Use this form during an HCTC Program-sponsored group
registration for the monthly Health Coverage Tax Credit
(HCTC) Program.

Complete Form 13441-EZ as Follows:
Part 1. Complete each line.
Part 2. Complete this section to confirm your eligibility for
the HCTC.
Eligibility Requirements for the HCTC:
You must be:

•

An eligible Trade Adjustment Assistance (TAA),
Alternative TAA (ATAA), or Reemployment TAA
(RTAA) recipient; OR a Pension Benefit
Guaranty Corporation (PBGC) payee who is 55
years old or older.

•

Covered by a qualified health plan for which you
paid the premiums, or your portion of the
premiums, directly to your health plan.

•

Paying more than 50% of your health insurance
premium after-tax (i.e., an employer does not pay
50% or more of your premium).
Not enrolled in Medicare Part A, B, or C.

•
•

Not enrolled in Medicaid or the Children’s Health
Insurance Program (CHIP).

•

Not enrolled in the Federal Employees Health
Benefits Program (FEHBP).

•

Not enrolled in the U.S. military health system
(TRICARE).

•

Not imprisoned under federal, state, or local
authority.

•

Not claimed as a dependent on someone else’s
federal income tax return.

Part 3. Complete this section to confirm the eligibility of your
family member(s) for the HCTC.
Eligibility Requirements for the HCTC:
Your family member(s) must:

•

Be your spouse or claimed as dependent(s) on your
federal income tax return.

•

Meet the same requirements listed in Part 2 except
the first and last bullets.

Instructions for Form 13441-EZ (Rev. 6-2011)

To assign your family member as your third-party
designee, create a five-digit Personal Identification
Number (PIN). This person will be able to make
changes to your account information, as well as ask
and answer questions about your personal information.
Part 4. Complete this section to confirm your qualified health
insurance.
If you have a health plan through a VEBA:
You must attest by signing this form that you chose
this health plan through a VEBA that was established
as a result of your former employer’s bankruptcy, and
was offered to you in lieu of COBRA coverage and
retiree benefits.
Part 5. If certain information is not provided by your former
employer, you may need to provide a copy of your
health insurance bill dated within the last 60 days. If
you have COBRA coverage, you may need to provide
additional documents. Visit www.irs.gov/hctc and click
on the “monthly HCTC” link for more information on
supporting documents.
Part 6. Print your full name, sign, and date the form.
Paperwork Reduction Act Notice and Privacy Act Statement
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 54947M

Department of the Treasury — Internal Revenue Service

Form 13441-EZ
(Rev. June 2011)

Department of the Treasury–Internal Revenue Service

Monthly Health Coverage Tax Credit (HCTC)
Group Registration

OMB Number
1545-1842

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

Gender
Male
Female
Date of Birth (mm/dd/yyyy)

Primary Telephone Number (include area code)

Former Employer

Part 2: Confirm Eligibility
Check the box below to confirm your eligibility for the HCTC.
I certify that I meet all eligibility requirements for the HCTC as outlined in Part 2 of the Instructions.

Part 3: Provide information about family member(s)
Check the box below to confirm the eligibility of your family member(s) for the HCTC.
I certify that each family member listed meets all eligibility requirements for the HCTC as outlined in Part 3 of the Instructions.
Make a copy of this page before filling it out if you have more family members than the space allows and indicate the number of
family members here. Number of family members
Family member’s name (first, middle initial, last, suffix)

Relationship to you
Spouse
Child

Social security number (SSN)

Date of birth (mm/dd/yyyy)

Other

Is this person on your health plan?
Yes
No This person has a separate plan (use Part 4 to provide this health insurance information, as applicable).
Is this person your third-party designee? (See Part 3 of the Instructions) If yes, create a five-digit Personal Identification Number (PIN)
Yes
No

Part 4: Provide information about your qualified health insurance
If your family member is not on your health plan, make a copy of this page to provide their qualified health insurance information.
Please see
Part 4 of the
Instructions
and complete
this section.

Type of Coverage:
COBRA
VEBA

Name of health plan

Health Plan ID number

State-qualified

Please provide at least one of the following ID Numbers.

Member ID

Group ID

Policy or Plan ID
Start date for coverage (mm/dd/yyyy)

Policy holder’s name (first, middle initial, last, suffix)

Total monthly premium

Policy holder’s social security number
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
Portion of monthly premium that covers a separate dental or vision plan
Complete this
section only if
you have
COBRA
coverage.

Former employer’s HR phone number (include area code)

Your former employer
End date for COBRA coverage (mm/dd/yyyy)

Check here if this is a Lifetime Benefit

Part 5: Gather supporting documents
Please see Part 5 of the Instructions for information on supporting documents.

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 authorize the HCTC Program to independently discuss with my health insurer, third party administrator
or former employer, my eligibility status and HCTC payments made on my behalf to these organizations.

Signature

Catalog Number 54947M

Full Name (print)

Date

Form 13441-EZ (Rev. 6-2011)