Department of the Treasury–Internal Revenue Service 
Form 13973                                                                                                                                                         OMB Number 
                                                                                                                                                                   1545-1891
(November 2016)       Health Coverage Tax Credit (HCTC) Blank Payment Coupon 
Instructions 
Use this HCTC payment coupon if you received a notification letter from the IRS stating you have successfully enrolled in 
the HCTC Program.
      Step 1:   Complete the information requested in the spaces provided directly below. You can find your HCTC 
                Participant Identification Number at the top of your enrollment notification letter. We strongly recommend 
                that you complete Step 1 prior to printing, as it will auto-populate the coupon below. Electronic completion of 
                this form will assist with the accurate and timely processing of your payment. 

                HCTC Participant Identification Number: 

                Re-enter HCTC Participant Identification Number: 

                Participant Name: 

                Street Address: 

                City, State and Zip: 

                Amount Paid:                                                                           $ ,           . 
      Step 2:   Print this document. 
      Step 3:   Cut off the payment coupon where indicated below. 
      Step 4:   Send the payment coupon along with your payment to: 
                US Treasury – HCTC 
                P.O. Box 970023 
                St. Louis, MO 63197-0023 

Payment Details 
The HCTC Program accepts the following payment methods by mail: personal check, business check, certified check, 
cashier's check, and money order. Make your check payable to US Treasury – HCTC. Write your HCTC Participant 
Identification Number on your check. Checks must be drawn from a bank within the United States. Checks will be 
processed upon receipt; post-dated checks will not be held for a later deposit. When you provide a check as payment, you 
authorize the HCTC Program to process the payment as a check transaction.  
Failure to provide all required information could delay processing of your payment. 
Privacy ACT and 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. 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. This information will be 
used by the Treasury Department to transmit payment data, by electronic means to vendor's financial institution. Failure to provide the requested information may delay or prevent the receipt of payments 
through the Automated Clearing House Payment System. 
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 10 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.
Cut along this line and remit the below payment coupon with your payment. 

HCTC Participant 
Identification Number:
Participant Name: 
                                                                                                         Please make payments payable to:  
Street Address: 
                                                                                                         US Treasury – HCTC   
City, State and Zip:                                                                                     P.O. Box 970023   
                                                                                                         St. Louis, MO 63197-0023 
Amount Paid: 
                      $      ,                       . 

Please do not write below this line. Do not send cash. Do not fold, staple, or paper clip this coupon. 

Catalog Number 51388X                                  www.irs.gov                                                                                            Form 13973 (Rev. 11-2016)