2017-10-03_SS_1545-2152r

SUPPORTING STATEMENT

Internal Revenue Service

OMB 1545-2152

Form 14095

Health Coverage Tax Credit (HCTC) Reimbursement Request Form

1. CIRCUMSTANCES NECESSITATING COLLECTION OF INFORMATION

As part of the American Recovery and Reinvestment Act (ARRA) changes relating to the Health Coverage Improvement, Section 1899B authorizes that retroactive payments be made to eligible individuals for months occurring prior to the first month for which and advance payment is made on behalf of the eligible individual.

2. USE OF DATA

The information provided by the respondent will be used to determine the amount for the retroactive payment to be made to the participant for monthly premiums paid prior to the commencement of advance payment of the federal tax credit.

3. USE OF IMPROVED INFORMATION TECHNOLOGY TO REDUCE BURDEN

The reimbursement request form will be posted to the Health Coverage Tax Credit (HCTC) website allowing respondents to download the form directly.

4. EFFORTS TO IDENTIFY DUPLICATION

Respondents submitting reimbursement will be asked to specify months during the calendar year for which they are requesting retroactive payment and will be asked to submit supporting documents for each month. Payment history is recorded in HCTC's customer relationship management system to avoid duplication of payments. The information obtained through this collection is unique and is not already available for use or adaptation from another source.

5. METHODS TO MINIMIZE BURDEN ON SMALL BUSINESSES OR OTHER SMALL ENTITIES

The reimbursement form does not collect information from small businesses

6. CONSEQUENCES OF LESS FREQUENT COLLECTION ON FEDERAL PROGRAMS OR POLICY ACTIVITIES

Section 1899B authorizes individuals to request retroactive payments. Without collecting the information request on the reimbursement form, the HCTC will have no way of knowing how much and for what months the individual may request retroactive payments for.

7. SPECIAL CIRCUMSTANCES REQUIRING DATA COLLECTION TO BE INCONSISTENT WITH GUIDELINES IN 5 CFR 1320.5(d)(2)

There are no special circumstances requiring data collection to be inconsistent with guidelines in 5 CFR 1320.5(d)(2).

8. CONSULTATION WITH INDIVIDUALS OUTSIDE OF THE AGENCY ON AVAILABILITY OF DATA, FREQUENCY OF COLLECTION, CLARITY OF INSTRUCTIONS AND FORMS, AND DATA ELEMENTS

Periodic meetings are held between IRS personnel and representatives of the American Bar Association, the National Society of Public Accountants, the American Institute of Certified Public Accountants, and other professional groups to discuss tax law and tax forms. During these meetings, there is an opportunity for those attending to make comments regarding the Health Coverage Tax Credit (HCTC) Reimbursement Request Form.

In response to the Federal Register notice (78 FR 19078), dated March 28, 2013, we received no comments during the comment period regarding the Health Coverage Tax Credit (HCTC) Reimbursement Request Form.

9. EXPLANATION OF DECISION TO PROVIDE ANY PAYMENT OR GIFT TO RESPONDENTS Retroactive payments will be made to eligible individuals for months occurring prior to the first month for which an advance payment is made on behalf of eligible individual.

10. ASSURANCE OF CONFIDENTIALITY OF RESPONSES

The reimbursement request form contains the following section, "PRIVACY ACT STATEMENT. The following information is provided to comply with the Privacy Act of 1974 (P.L.93-579)."

11. JUSTIFICATION OF SENSITIVE QUESTIONS

The reimbursement request form requests limited sensitive information regarding health plan coverage and qualified family members solely for the purpose of processing retroactive payments.

A privacy impact assessment (PIA) has been conducted for information collected under this request as part of the “Health Coverage Tax Credit Program-Closeout Phase (HCTC)” and a Privacy Act System of Records notice (SORN) has been issued for this system under IRS SORN: Treasury/IRS 22.012-Health Coverage Tax Credit Program Records 34.037-IRS Audit Trail and Security Records System; The Internal Revenue Service PIAs can be found at http://www.irs.gov/uac/Privacy-Impact-Assessments-PIA

12. ESTIMATED BURDEN OF INFORMATION COLLECTION

It is estimated the reimbursement request form will be used by 3,058 respondents one time annually. The total number of hours estimated for respondents is 1,529 annually. Respondents for the reimbursement request are from an unemployed population, therefore it is estimated that there is no cost for their time.

Authority	Description	# of Respondents	# Responses per Respondent	Annual Responses	Hours per Response	Total Burden
ARRA 1899B	Form 14095	3058	1	3058	.50	1,529
Totals				3058		1,529

13. ESTIMATED TOTAL ANNUAL COST BURDEN TO RESPONDENTS

To ensure more accuracy and consistency across its information collections, IRS is currently in the process of revising the methodology it uses to estimate burden and costs. Once this methodology is complete, IRS will update this information collection to reflect a more precise estimate of burden and costs.

14. ESTIMATED ANNUALIZED COST TO THE FEDERAL GOVERNMENT

No additional equipment will be needed, and there will be minimal printing costs as the primary method for distribution of the form will be to download it from the HCTC website.

15. REASONS FOR CHANGE IN BURDEN

IRS is making this submission for reinstatement. The Health Coverage Tax Credit (HCTC) was reauthorized into law June 29, 2015 and will remain in effect through December 31, 2019.

16. PLANS FOR TABULATION, STATISTICAL ANALYSIS AND PUBLICATION

There are no plans for tabulation, statistical analysis and publication.

17. REASONS WHY DISPLAYING THE OMB EXPIRATION DATE IS INAPPROPRIATE

We believe that displaying the OMB expiration date is inappropriate because it could cause confusion by leading taxpayers to believe that the form sunsets as of the expiration date. Taxpayers are not likely to be aware that the Service intends to request renewal of the OMB approval and obtain a new expiration date before the old one expires.

18. EXCEPTIONS TO THE CERTIFICATION STATEMENT ON OMB PRA SUBMISSION FORM

None.

Note: The following paragraph applies to all of the collections of information in this submission:

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless the collection of information displays a valid OMB control number. Books or records relating to a collection of information must be retained as long as their contents may become material in the administration of any internal revenue law. Generally, tax returns and tax return information are confidential, as required by 26 U.S.C. 6103.

19. REASON FOR EMERGENCY SUBMISSION

The Health Coverage Tax Credit (HCTC) was reauthorized into law June 29, 2015 and will remain in effect through December 31, 2019. The HCTC provides premium assistance for 72.5% of healthcare premiums. Per this legislation, taxpayers may request reimbursement credit of premiums. The taxpayers must file the Form 14095 with the IRS. The Form 14095 is used to request an HCTC reimbursement credit for premiums you paid directly to a qualified health plan while they were eligible and enrolling in the monthly HCTC Program. The taxpayer must be a Monthly HCTC Participant or have an HCTC registration in process for your request to be considered.