The Health Coverage Tax Credit (HCTC) Reimbursement Request Form

Form 14095--The Health Coverage Tax Credit (HCTC) Reimbursement Request Form

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1545-2152 can be found here:

Documents and Forms

Document Name Document Type
Form 14095 The Health Coverage Tax Credit (HCTC) Reimbursement Request Form Form and Instruction
14095 The Health Coverage Tax Credit (HCTC) Reimbursement Requ Form 14095 01-2017.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	The Health Coverage Tax Credit (HCTC) Reimbursement Request Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	14095	The Health Coverage Tax Credit (HCTC) Reimbursement Request Form	Form 14095 01-2017.pdf		Yes	No	Fillable Printable

Line of Business: General Government

Subfunction: Taxation Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,058	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	3,058	3,058
Annual IC Time Burden (Hours)	2,039	2,039
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.