The Health Coverage Tax Credit (HCTC) Reimbursement Request Form

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

OMB: 1545-2152

IC ID: 190222

Information Collection (IC) Details

View Information Collection (IC)

The Health Coverage Tax Credit (HCTC) Reimbursement Request Form
 
No Modified
 
Required to Obtain or Retain Benefits
 

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

General Government Taxation Management

 

3,058 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 3,058 0 3,058 0 0 0
Annual IC Time Burden (Hours) 2,039 0 2,039 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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