Form 8962 Premium Tax Credit (PTC)

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Form

8962

OMB No. 1545-0074

Premium Tax Credit (PTC)

Department of the Treasury
Internal Revenue Service
Name shown on your return

▶

2019

▶ Attach to Form 1040, 1040-SR, or 1040-NR
Go to www.irs.gov/Form8962 for instructions and the latest information.

Attachment
Sequence No. 73

Your social security number

DRAFT AS OF
August 9, 2019
DO NOT FILE

You cannot take the PTC if your filing status is married filing separately unless you qualify for an exception (see instructions). If you qualify, check the box

Part I
1
2a
b
3

5
6

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Annual and Monthly Contribution Amount

Tax family size. Enter your tax family size (see instructions) .
Modified AGI. Enter your modified AGI (see instructions) .

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Enter the total of your dependents’ modified AGI (see instructions) . . .
Household income. Add the amounts on lines 2a and 2b (see instructions) .

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2a

2b
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1

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3

Federal poverty line. Enter the federal poverty line amount from Table 1-1, 1-2, or 1-3 (see instructions). Check the
appropriate box for the federal poverty table used. a
Alaska
b
Hawaii
c
Other 48 states and DC
Household income as a percentage of federal poverty line (see instructions)
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Did you enter 401% on line 5? (See instructions if you entered less than 100%.)

4

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4
5

%

No. Continue to line 7.

Yes. You are not eligible to take the PTC. If advance payment of the PTC was made, see the instructions for
how to report your excess advance PTC repayment amount.

7

Applicable Figure. Using your line 5 percentage, locate your “applicable figure” on the table in the instructions

8a

Annual contribution amount. Multiply line 3 by
line 7. Round to nearest whole dollar amount

Part II
9

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b Monthly contribution amount. Divide line 8a
by 12. Round to nearest whole dollar amount

8a

7

8b

Premium Tax Credit Claim and Reconciliation of Advance Payment of Premium Tax Credit

Are you allocating policy amounts with another taxpayer or do you want to use the alternative calculation for year of marriage (see instructions)?
Yes. Skip to Part IV, Allocation of Policy Amounts, or Part V, Alternative Calculation for Year of Marriage.
No. Continue to line 10.
See the instructions to determine if you can use line 11 or must complete lines 12 through 23.
Yes. Continue to line 11. Compute your annual PTC. Then skip lines 12–23
No. Continue to lines 12–23. Compute
and continue to line 24.
your monthly PTC and continue to line 24.

10

Annual
Calculation
11

(a) Annual enrollment
premiums (Form(s)
1095-A, line 33A)

(b) Annual applicable
SLCSP premium
(Form(s) 1095-A,
line 33B)

(d) Annual maximum
premium assistance
(subtract (c) from (b), if
zero or less, enter -0-)

(c) Annual
contribution amount
(line 8a)

(e) Annual premium tax
(f) Annual advance
credit allowed
payment of PTC (Form(s)
1095-A, line 33C)
(smaller of (a) or (d))

Annual Totals

Monthly
Calculation

(a) Monthly enrollment (b) Monthly applicable
premiums (Form(s)
SLCSP premium
1095-A, lines 21–32, (Form(s) 1095-A, lines
column A)
21–32, column B)

(c) Monthly
contribution amount
(amount from line 8b
or alternative marriage
monthly calculation)

(d) Monthly maximum
(f) Monthly advance
(e) Monthly premium tax
premium assistance
payment of PTC (Form(s)
credit allowed
(subtract (c) from (b), if
1095-A, lines 21–32,
(smaller of (a) or (d))
zero or less, enter -0-)
column C)

12
13
14
15
16
17
18
19
20
21
22
23

January
February
March
April
May
June
July
August
September
October
November
December

24

Total premium tax credit. Enter the amount from line 11(e) or add lines 12(e) through 23(e) and enter the total here

24

25

Advance payment of PTC. Enter the amount from line 11(f) or add lines 12(f) through 23(f) and enter the total here

25

26

Net premium tax credit. If line 24 is greater than line 25, subtract line 25 from line 24. Enter the difference here and
on Schedule 3 (Form 1040 or 1040-SR), line 9, or Form 1040-NR, line 65. If line 24 equals line 25, enter -0-. Stop
here. If line 25 is greater than line 24, leave this line blank and continue to line 27 . . . . . . . . . .

26

Part III

Repayment of Excess Advance Payment of the Premium Tax Credit

27

Excess advance payment of PTC. If line 25 is greater than line 24, subtract line 24 from line 25. Enter the difference here

27

28

Repayment limitation (see instructions)

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Excess advance premium tax credit repayment. Enter the smaller of line 27 or line 28 here and on Schedule 2
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(Form 1040 or 1040-SR), line 2, or Form 1040-NR, line 44 . . . . . . . . . . . . . . . . .
For Paperwork Reduction Act Notice, see your tax return instructions.
Cat. No. 37784Z

29

Form 8962 (2019)

Form 8962 (2019)

Part IV

Page

2

Allocation of Policy Amounts

Complete the following information for up to four policy amount allocations. See instructions for allocation details.

Allocation 1
30

(a) Policy Number (Form 1095-A, line 2)

(b) SSN of other taxpayer

(c) Allocation start month

(d) Allocation stop month

DRAFT AS OF
August 9, 2019
DO NOT FILE
Allocation percentage
applied to monthly
amounts

(e) Premium Percentage

(f) SLCSP Percentage

(g) Advance Payment of the PTC
Percentage

Allocation 2
31

(a) Policy Number (Form 1095-A, line 2)

Allocation percentage
applied to monthly
amounts

(b) SSN of other taxpayer

(e) Premium Percentage

(c) Allocation start month

(f) SLCSP Percentage

(d) Allocation stop month

(g) Advance Payment of the PTC
Percentage

Allocation 3
32

(a) Policy Number (Form 1095-A, line 2)

Allocation percentage
applied to monthly
amounts

(b) SSN of other taxpayer

(e) Premium Percentage

(c) Allocation start month

(f) SLCSP Percentage

(d) Allocation stop month

(g) Advance Payment of the PTC
Percentage

Allocation 4
33

(a) Policy Number (Form 1095-A, line 2)

Allocation percentage
applied to monthly
amounts
34

(b) SSN of other taxpayer

(e) Premium Percentage

(c) Allocation start month

(f) SLCSP Percentage

(d) Allocation stop month

(g) Advance Payment of the PTC
Percentage

Have you completed all policy amount allocations?
Yes. Multiply the amounts on Form 1095-A by the allocation percentages entered by policy. Add all allocated policy amounts and nonallocated policy amounts from Forms 1095-A, if any, to compute a combined total for each month. Enter the combined total for each month on
lines 12–23, columns (a), (b), and (f). Compute the amounts for lines 12–23, columns (c)–(e), and continue to line 24.
No. See the instructions to report additional policy amount allocations.

Part V

Alternative Calculation for Year of Marriage

Complete line(s) 35 and/or 36 to elect the alternative calculation for year of marriage. For eligibility to make the election, see the instructions for line 9.
To complete line(s) 35 and/or 36 and compute the amounts for lines 12–23, see the instructions for this Part V.
35

Alternative entries
for your SSN

36

Alternative entries
for your spouse’s
SSN

(a) Alternative family size (b) Alternative monthly
contribution amount

(c) Alternative start month

(d) Alternative stop month

(a) Alternative family size (b) Alternative monthly
contribution amount

(c) Alternative start month

(d) Alternative stop month

Form 8962 (2019)