Document
Form 14095 (Rev. 1-2017)
ICR 202004-1545-008 · OMB 1545-0074 · Object 100093701.
This document may belong to an older filing. More recent activity for OMB 1545-0074:
Document Viewer [pdf]
Status: No verified local artifact is currently available. The document remains flagged for repair and upstream re-check.
Queue: Repair is queued and waiting for the next worker pass. (priority 20 · next 2026-06-04 16:47:49)
Missing: pdf
No local or Spaces-backed artifact is available yet for this document.
Loading document viewer…
Document Metadata
| File Type | application/octet-stream |
|---|---|
| File Title | Form 14095 (Rev. 1-2017) |
| Subject | The Health Coverage Tax Credit (HCTC) Reimbursement Request Form |
| Author | SE:W:SS:OPCI |
| File Modified | 2017-01-27 |
| File Created | 2017-01-27 |
| Conversion State | failed_conversion |