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Enter the TOTALS for ALL MONTHS checked above
1. Enter the total amount you paid directly to your qualified health plan
2. Enter the total amount you paid for dental or vision benefits. These benefits do not qualify for the HCTC
3. Subtract line 2 from line 1. Enter the total
4. Enter total amount you paid for family members that are not qualified for the HCTC
5. Subtract line 4 from line 3. Enter the total
6. Multiply line 5 by 72.5% (0.725). Enter the total. This is your Total Requested Reimbursement
Part 4: Gather Supporting Documents
You must provide copies of the corresponding health insurance bills for the months identified in Part 3 of this form. These documents
must show the following information:
• Your name (or name of the policy holder)
• Social Security number of Policy Holder if different from requester
• The name of your health plan
• Your monthly premium amount
• Dates of coverage
• Your health plan identification number(s) including member ID, Group ID, Policy or Plan ID
Note: If your qualified health plan does not provide members with an insurance bill or COBRA payment coupon, you must provide
health plan enrollment documents or an official letter from your health plan that has the required information listed in the bullets above.
You must also provide proof that you paid those premiums. Acceptable proof of payment includes:
• Canceled checks (copy of front and back)
• Bank statements
• Credit card statements
• Money Order receipts
Note: Your proof of payment must indicate the amount paid and to whom it was paid. If you do not have one of these types of proof of
payment, contact your health plan for a record of your payment(s).
Part 5: Sign and Date This Form
Under penalties of perjury, I declare that the information furnished on this form with regard to myself and to any family member(s), and
any attachments to it, is true, correct, and complete. I understand that a knowing and willfully false statement on this form or any
attachment to it can result in my disqualification from the HCTC AMP program. By signing, I authorize the IRS to independently discuss
with my health insurer, third party administrator or former employer, my eligibility status and HCTC payments made on my behalf to
these organizations.
Signature Full name (print or type) Date
If you have any questions about this form, contact the Internal Revenue Service toll-free at 1-844-853-7210.
Note: Only months during the current calendar year are eligible for reimbursement request. If you were eligible for the HCTC and made
payments directly to your Health Plan for months prior to the current calendar year, you may be able to claim these amounts on your
federal tax return for that year, see Form 8885 Instructions.
Paperwork Reduction Act Notice And Privacy Act Statement
PAPERWORK REDUCTION ACT NOTICE. We ask for the information on this form to carry out the Internal Revenue laws of the United States. Your
response is voluntary. You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the
form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become
material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by code section
6103. The estimated average time to complete this form is 15 minutes. If you have comments concerning the accuracy of this time estimate or
suggestions for making this form simpler, we will be happy to hear from you. You can write to the Tax Products Coordinating Committee, SE:W:CAR:
MP:T:T:SP, 1111 Constitution Ave. NW, Washington, DC 20224.
PRIVACY ACT STATEMENT. The following information is provided to comply with the Privacy Act of 1974 (P.L.93-579). All information collected on this
form is required under the provisions of 31 U.S.C. 3322 and 31 CFR 210. We use the information you submit to determine if you qualify for
reimbursement of the monthly credit of the Health Coverage Tax Credit (HCTC). If you fail to provide the information, or provide inaccurate information,
your application may be denied. However, you may still qualify for the Yearly HCTC when you file your federal income tax return.
Catalog Number 53672K www.irs.gov Form 14095 (Rev. 4-2020)
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