State Election of Qualified Health Insurance for Health Coverage Tax Credit (HCTC)

OMB 1545-1875

OMB 1545-1875

Revenue Procedure 2004-12 informs states how to elect a health program to be qualified health insurance for purposes of the health coverage tax credit (HCTC) under section 35 of the Internal Revenue Code. The collection of information is voluntary. However, if a state does not make an election, eligible residents of the state may be impeded in their efforts to claim the HCTC.

The latest form for State Election of Qualified Health Insurance for Health Coverage Tax Credit (HCTC) expires 2021-05-31 and can be found here.

Latest Forms, Documents, and Supporting Material
Document
Name
Supporting Statement A
All Historical Document Collections
Approved without change
 Extension without change of a currently approved collection 2021-05-28
Approved without change
 Extension without change of a currently approved collection 2020-03-31
Approved without change
 Extension without change of a currently approved collection 2016-12-19
Approved without change
 Extension without change of a currently approved collection 2013-09-30
Approved without change
 Extension without change of a currently approved collection 2010-07-26
Approved without change
 Extension without change of a currently approved collection 2007-04-26
Approved without change
 Extension without change of a currently approved collection 2004-04-28
Approved without change
 New collection (Request for a new OMB Control Number) 2004-01-16
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