Form 13704 Monthly HCTC Registration Update Form

Form 13704
(Rev. April 2011)

Department of the Treasury–Internal Revenue Service

OMB Number
1545-1954

MONTHLY HCTC REGISTRATION UPDATE

Use this form to make updates to your monthly Health Coverage Tax Credit (HCTC) account. When you or your family members are
enrolled in the monthly HCTC program, you must inform us of all changes that affect your eligibility, your family members, and your
health insurance. If you do not keep your HCTC account information current, you could risk losing the Monthly HCTC.

Instructions:
1.
2.
3.
4.
5.
6.
7.

Keep a blank copy of this form in your personal records for future use. This form can also be found at www.irs.gov/hctc.
Only use this form if you need to make changes to your HCTC account.
Print or type your responses. Leave blank any box that does not apply to you or your family members.
You must complete Part 5.
You must sign and date this form to confirm your continued eligibility for the HCTC.
Keep a copy of this completed Registration Update Form—and all required supporting documents—for your personal records.
DO NOT SEND PAYMENT WITH THIS FORM. Mail the completed form and required supporting documents to:
HCTC Processing Center
P.O. Box 760189
San Antonio, TX 78245

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 1: Provide information about you
Gender
Male

Name (First, Middle Initial, Last, Suffix)
Social Security Number (SSN)

Date of Birth (mm/dd/yyyy)

Your Mailing Address (Street Address)

Primary Phone Number

Female

Check here if address or
phone has changed

City, State, Zip

Note: You must also provide mailing address changes to the agency that reports you as eligible for the HCTC Program. This is
either your state (unemployment office) or the Pension Benefit Guaranty Corporation (PBGC).

Part 2: Confirm your eligibility
Check the box below to confirm your eligibility for the HCTC.
I certify that all of the following statements are true.
• I am an eligible Trade Adjustment Assistance (TAA), Alternative TAA (ATAA), or Reemployment TAA (RTAA) recipient;
OR a Pension Benefit Guaranty Corporation (PBGC) payee.
• I am covered by a qualified health plan for which I pay more than 50% of the premiums. (An employer does not pay 50% or
more of my premiums.)
• I am not enrolled in Medicare Part A, B, or C.
• I am not enrolled in Medicaid or the Children's Health Insurance Program (CHIP).
• I am not enrolled in the Federal Employees Health Benefits Program (FEHBP).
• I am not enrolled in the U.S. military health system (TRICARE).
• I am not imprisoned under federal, state, or local authority.
• I am not claimed as a dependent on someone else's federal income tax return.
If you do not certify all of the statements above, you are no longer eligible to receive the HCTC and should not submit this
form. Instead, call the HCTC Customer Contact Center to tell us about this change.

Part 3: Tell us what to change on your HCTC account
Effective Date of
Change (mm/dd/yyyy)

Check all that apply.
Add or remove a family member.
Change information about my or my family member’s current health insurance (e.g., change in
premium amount, change in any ID numbers, change in address where payments are currently sent).
The administrator for my COBRA coverage has changed (COBRA only).
I or my family member(s) have new HCTC qualified health insurance.
Switch my eligibility type from TAA (or ATAA/RTAA) to PBGC.
Check this box to reactivate my HCTC account if I was enrolled within the last 90 days.

Reason for update

Catalog Number 40924D

Form 13704 (Rev. 4-2011)

Add eligible family member
Remove ineligible family member

Part 4: Provide information about a family member

Make a copy of this page before filling it out if you have more family members than the space allows.
Family Member’s Name (First, Middle Initial, Last, Suffix)

Relationship to You

Social Security Number

Date of Birth (mm/dd/yyyy)

Spouse

Child

Other

Is this person on your health plan?
Yes

No This person has a separate plan. Make a copy of this page and use Part 5 to provide this health insurance
information, as applicable.

Part 5: Provide information about your qualified health insurance
Part 5 is required. You must submit proof of insurance (e.g., a current bill) and any other required documents for the
health insurance policy you describe below. For detailed information on the supporting documents you must submit,
visit www.irs.gov/hctc.
Please
complete
this section.

Type of Coverage:
COBRA
State-qualified

VEBA (Only certain VEBAs qualify for the HCTC)

Non-group/individual

Name of Health Plan

Health Plan ID Number

Please provide at least one of the following ID Numbers.

Member ID

Group ID

Policy or Plan ID

Policy Holder’s Name (First, Middle Initial, Last, Suffix)

Policy Holder’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
Portion of monthly premium that covers a separate dental or vision plan
Complete this
section only if
you have
COBRA
coverage.*

Former Employer

Former Employer’s HR Phone Number

Start Date for COBRA Coverage (mm/dd/yyyy)

End Date for COBRA Coverage (mm/dd/yyyy)
Check here if this is a Lifetime Benefit

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

Employer that made You Eligible for PBGC or TAA Benefits

Employer’s Phone Number

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. For a list of the supporting documents visit
www.irs.gov/hctc and click the “Monthly HCTC” link.

Part 6: Sign and date this form to confirm your HCTC eligibility
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

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 40924D

Form 13704 (Rev. 4-2011)