The Health Coverage Tax Credit (HCTC) Reimbursement Request Form

OMB 1545-2152

This form will be used by HCTC participants to request reimbursement for health plan premiums paid prior to the commencement of advance payments.

The latest form for The Health Coverage Tax Credit (HCTC) Reimbursement Request Form expires 2022-02-28 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form 14095 The Health Coverage Tax Credit (HCTC) Reimbursement Request Form Form and Instruction
SS 1545-2152_2021.docx Supporting Statement A
The Health Coverage Tax Credit (HCTC) Reimbursement Request Form Form and Instruction

All Historical Document Collections

202111-1545-022 Approved without change	Revision of a currently approved collection	2022-02-28
201802-1545-011 Approved without change	Extension without change of a currently approved collection	2018-06-27
201707-1545-017 Approved without change	Reinstatement without change of a previously approved collection	2017-10-05
201302-1545-006 Approved without change	Extension without change of a currently approved collection	2013-03-28
201002-1545-017 Approved without change	Extension without change of a currently approved collection	2010-02-25
200908-1545-006 Approved without change	New collection (Request for a new OMB Control Number)	2009-08-10