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Department of the Treasury
Internal Revenue Service
2020

Instructions for Form 8885

Health Coverage Tax Credit
Section references are to the Internal Revenue
Code unless otherwise noted. Who Can Take This Credit Definitions and Special
You can elect to take the HCTC only if (a) Rules
you were an eligible TAA, ATAA, or RTAA
What’s New TAA Recipient
recipient or PBGC payee in 2020; or you
Expiration of the Health Coverage Tax were the qualifying family member of an You were an eligible TAA recipient as of
Credit (HCTC). The HCTC expires at the eligible TAA, ATAA, or RTAA recipient or the first day of the month if, for any day in
end of 2020. The HCTC can't be claimed PBGC payee who passed away or that month or the prior month, you:
for coverage months beginning in 2021. finalized a divorce with you (see • Received a trade readjustment
The advance monthly payment program Continued Qualification for Family allowance, or
will continue through December 2020 but Members After Certain Life Events, later); • Would have been entitled to receive
will not accept HCTC payments in 2021. (b) you can’t be claimed as a dependent such an allowance except that you hadn’t
on someone else’s 2020 tax return; and exhausted all rights to any unemployment
Future Developments (c) you met all of the other conditions insurance (except additional
For the latest information about listed on line 1. If you can’t be claimed as compensation that is funded by a state
developments related to Form 8885 and a dependent on someone else’s 2020 tax and isn’t reimbursed from any federal
its instructions, such as legislation return, review Form 8885, Part I, to see if funds) to which you were entitled (or
enacted after they were published, go to you are eligible to take this credit. would be entitled if you applied).
IRS.gov/Form8885. Election to take the HCTC. You must Example. You received a trade
Relatively few people are eligible elect the HCTC to receive the benefit of readjustment allowance for January 2020.
the HCTC. Make your election by You were an eligible TAA recipient as of
! for the HCTC. See Who Can Take checking the box on line 1 for the first the first day of January and February.
CAUTION This Credit, later, to determine
whether you can claim the credit. eligible coverage month you are electing
to take the HCTC and all boxes on line 1 ATAA Recipient
for each eligible coverage month after the You were an eligible ATAA recipient as of
election month. Once you elect to take the the first day of the month if, for that month
General Instructions
HCTC for a month in 2020, the election to or the prior month, you received benefits
take the HCTC applies to all subsequent under an alternative trade adjustment
Purpose of Form eligible coverage months in 2020. The assistance program for older workers
Use Form 8885 to elect and figure the election doesn’t apply to any month for established by the Department of Labor.
amount, if any, of your HCTC. which you aren’t eligible to take the HCTC. Example. You received benefits under
Self-Employed Health Insurance De- For 2020, the election must be made an alternative trade adjustment assistance
duction Worksheet. If you are not later than the due date (including program for older workers for October
completing the Self-Employed Health extensions) of your tax return. 2020. The program was established by
Insurance Deduction Worksheet in your Example. You were an eligible RTAA the Department of Labor. You were an
tax return instructions and you were an recipient between February 2020 and eligible ATAA recipient as of the first day
eligible trade adjustment assistance (TAA) October 2020 and you otherwise met the of October and November.
recipient, alternative TAA (ATAA) HCTC requirements during that period. RTAA Recipient
recipient, reemployment TAA (RTAA) You wish to take the HCTC starting in April
recipient, or Pension Benefit Guaranty 2020. You would check the box on line 1 You were an eligible RTAA recipient as of
Corporation (PBGC) payee, you must for April to elect the HCTC for your April the first day of the month if, for that month
complete Form 8885 before completing coverage. You must then check every box or the prior month, you received benefits
that worksheet. When figuring the amount on line 1 through and including October under a reemployment trade adjustment
to enter on line 1 of the worksheet, do not because you’re eligible to take the HCTC assistance program for older workers
include: for those coverage months. Your election established by the Department of Labor.
• Any amounts you included on Form applies to your April through October Example. You received benefits under
8885, line 4, or on Form 14095, The coverage months. a reemployment trade adjustment
Health Coverage Tax Credit (HCTC) assistance program for older workers for
Reimbursement Request Form; Even if you can’t claim the HCTC
January 2020. The program was
• Any qualified health insurance ! on your income tax return, you established by the Department of Labor.
coverage premiums you paid to “US CAUTION must still file Form 8885 to elect
Treasury-HCTC” for eligible coverage the HCTC for any months you participated You were an eligible RTAA recipient as of
months for which you received the benefit in the advance monthly payment program. the first day of January and February.
of the advance monthly payment program; Failing to make a timely election will PBGC Payee
or require you to report advance monthly You were an eligible PBGC payee as of
• Any advance monthly payments your HCTC payment amounts as an additional the first day of the month if both of the
health plan administrator received from tax owed on your tax return. following apply.
the IRS, as shown on Form 1099-H,
Health Coverage Tax Credit (HCTC) 1. You were age 55 to 65 and not
Advance Payments. enrolled in Medicare as of the first day of
the month.

Dec 16, 2020 Cat. No. 68158V

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2. You received a benefit for that connected with a group health plan or Qualifying Family Member
month that was paid by the PBGC under federal- or state-based health insurance A qualifying family member is:
title IV of the Employee Retirement coverage. Your spouse (a spouse doesn’t include
•
Income Security Act of 1974 (ERISA). 3. Coverage under a Consolidated someone who is legally separated from his
If you received a lump-sum payment Omnibus Budget Reconciliation Act or her spouse under a decree of divorce or
from the PBGC after August 5, 2002, you (COBRA) continuation provision (as of separate maintenance (but see Married
meet item (2) above for any month that defined in section 9832(d)(1)). Persons Filing Separate Returns, later)),
you would have received a PBGC benefit 4. State-based coverage. State-based or
if you hadn’t received the lump-sum coverage includes the following. • Anyone whom you can claim as a
payment. a. Continuation coverage provided by dependent (but see the exception for
Continued Qualification for the state under a state law that requires Children of Divorced or Separated
such coverage. Parents, later).
Family Members After Certain For any month that you are eligible to
b. A qualified state high-risk pool (as
Life Events defined in section 2744(c)(2) of the Public take the HCTC, you can include premiums
Qualifying family members (spouses and Health Service Act). paid for a qualifying family member for that
eligible coverage month if all of the
dependents) (see Qualifying Family c. A health insurance program offered following statements were true as of the
Member, later) can be considered for state employees. first day of that eligible coverage month.
recipients and file Form 8885 under their
name and social security number after d. A state-based health insurance • The qualifying family member was
certain life events. You are considered a program that is comparable to the health covered by qualified health insurance
recipient and are eligible to newly receive insurance program offered for state coverage for which you paid some or all of
or continue to receive the HCTC in the employees. the premiums. You and your qualifying
event that a related TAA, ATAA, or RTAA e. An arrangement entered into by a family member don’t have to be covered
recipient or PBGC payee dies or finalizes state and (i) a group health plan (including by the same coverage.
a divorce with you and you were a such a plan which is a multiemployer plan • The qualifying family member wasn’t
qualifying family member immediately as defined in section 3(37) of ERISA), (ii) enrolled in Medicare Part A, B, or C.
before such event. The TAA, ATAA, or an issuer of health insurance coverage, • The qualifying family member wasn’t
RTAA recipient or PBGC payee didn’t (iii) an administrator, or (iv) an employer. enrolled in Medicaid or the Children’s
Health Insurance Program (CHIP).
need to elect the HCTC prior to the event. f. A state arrangement with a private The qualifying family member wasn’t
•
People who were qualifying family sector health care coverage purchasing enrolled in the Federal Employees Health
members can receive the tax credit for pool. Benefits Program (FEHBP) or eligible to
eligible coverage months up to 24 months
from the death or divorce, or until the first g. A state-operated health plan that receive benefits under the U.S. military
coverage month that begins on or after doesn’t receive any federal financial health system (TRICARE).
January 1, 2021, whichever comes first. participation. • The qualifying family member wasn’t
Eligibility to receive the HCTC may begin 5. Coverage under a health plan covered by, or eligible for coverage under,
in either the month of the death or divorce funded by a voluntary employees’ any employer-sponsored health insurance
or the month following the death or beneficiary association (VEBA) that was coverage as described in the instructions
divorce. established through a bankruptcy court. for line 1, later.
Example. Your spouse was a PBGC Exception. Qualified health insurance Note. If you are an eligible TAA, ATAA, or
payee and died on August 20, 2019. You coverage doesn’t include any of the RTAA recipient or PBGC payee who
are eligible to receive the HCTC as a following. enrolled in Medicare, you may be able to
recipient for coverage for August 2019 • Any state-based coverage listed in take the HCTC for coverage of qualifying
through December 2020, subject to the items 4a through 4g above unless it also family members. You can receive the
other general HCTC requirements. If you meets the requirements of section 35(e) HCTC for the health plan premiums of
didn't have separate coverage for August, (2). your qualifying family member(s) for
you are eligible to receive the HCTC as a • A flexible spending or similar eligible coverage months up to 24 months
recipient for coverage for September 2019 arrangement. from the month you enrolled in Medicare,
through December 2020, subject to the • Any insurance if substantially all of its or until the first coverage month that
other general HCTC requirements. coverage is of excepted benefits begins on or after January 1, 2021,
Qualified Health Insurance described in section 9832(c). For whichever comes first. In order to receive
example, if you purchase dental or vision the HCTC, your qualifying family members
Coverage benefits separately, these benefits aren’t must meet all of the requirements
Qualified health insurance coverage for qualified health insurance coverage. But, if described earlier.
the HCTC is any of the following. you purchase dental or vision benefits as
Married Persons Filing
1. Coverage under a group health part of a comprehensive package and
plan available through the employment of these benefits don’t represent Separate Returns
your spouse, but see the instructions for substantially all of its coverage, the Your spouse isn’t treated as a qualifying
line 1, later, for information on when comprehensive package of benefits, family member if you and your spouse file
enrollment in or an offer of including the dental and vision benefits, separate returns and either (1) or (2)
employer-sponsored coverage makes you may be qualified health insurance below applies.
an individual ineligible for the HCTC. coverage and the premiums paid may be 1. Your spouse was also an eligible
2. Coverage under a non-group eligible for the HCTC. TAA, ATAA, or RTAA recipient or PBGC
(individual) health insurance plan other For more information about payee in 2020.
than a qualified health plan offered TIP whether your coverage is qualified 2. All of the following apply.
through a Marketplace. Individual health health insurance coverage, go to a. You lived apart from your spouse
insurance doesn’t include any insurance IRS.gov/HCTC. during the last 6 months of 2020.

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  b. A qualifying family member (other                 a child of divorced or separated parents                   You may also be able to claim the 
than your spouse) lived in your home for               but you aren’t the child’s custodial parent,            HCTC and the PTC for different coverage 
more than half of 2020.                                the child isn’t your qualifying family                  of the same individuals in different months 
  c. You provided over half of the cost                member for purposes of the HCTC.                        of the year but need to apply the following 
                                                                                                               special instructions for completing Form 
of keeping up your home.                                        The child must also meet all the 
                                                                                                               8962. If you elected to take the HCTC or 
                                                                other conditions of a qualifying 
Children of Divorced or                                CAUTION! family member defined earlier in               received the benefit of advance payments 
                                                                                                               of the HCTC for at least 1 month of the 
Separated Parents                                      order for you to claim the HCTC for the 
                                                                                                               year and the individual(s) covered under 
Even if you can’t claim your child as a                qualified health insurance coverage of the 
                                                                                                               the qualified health insurance coverage for 
dependent, he or she is treated as your                child.
                                                                                                               the HCTC were also enrolled in a qualified 
qualifying family member for the HCTC if                                                                       health plan offered through a Marketplace 
both of the following apply.                           Participants in a Health                                for at least 1 other month of the year, 
• You were the child’s custodial parent.               Insurance Marketplace                                   complete Form 8962 as provided in the 
Generally, the custodial parent is the                                                                         Form 8962 instructions, but:
                                                       A qualified health plan offered through a 
parent with whom the child resided for the                                                                     •  Figure your PTC for only those months 
                                                       Marketplace isn’t qualified health 
greater number of nights in 2020. If the                                                                       not checked on Form 8885, line 1;
                                                       insurance coverage for the HCTC in 2020. 
counting nights rule applies, and the child                                                                    •  Complete Form 8962, column (f) of 
                                                       And you can’t take the premium tax credit 
resided with each parent for an equal                                                                          lines 12 through 23, for all months for 
                                                       (PTC) for any months checked on line 1. 
number of nights in 2020, the custodial                                                                        which advance payments of the premium 
                                                       However, subject to the general eligibility 
parent is the parent with the higher                   and election rules for the HCTC and the                 tax credit (APTC) were made, even those 
adjusted gross income for 2020.                                                                                months checked on Form 8885, line 1; 
                                                       PTC, you may be able to claim the PTC 
• The child’s other parent can claim the                                                                       and
                                                       and the HCTC in the same month for 
child as a dependent under the rules for                                                                       •  If you complete Form 8962, line 27 
                                                       different coverage. For example, if you 
children of divorced or separated parents.                                                                     (Excess advance payment of PTC), 
                                                       elect the HCTC for self-only COBRA 
See the Instructions for Forms 1040 and                                                                        determine Form 8962, line 28 (Repayment 
                                                       coverage in a month, you can take the 
1040-SR, or Pub. 501, Dependents,                                                                              limitation), as follows.
                                                       PTC for the Marketplace coverage of your 
Standard Deduction, and Filing                         family members for that same month if you 
Information, for details.                              and they are otherwise eligible to take the 
  Conversely, if you can claim your child              PTC and the HCTC, as applicable.
as a dependent under the special rule for 
IF . . .                                                                 THEN . . .
the amount on Form 8962, line 5, is 400 or 401                           leave Form 8962, line 28, blank and enter the amount from line 27 on line 29.
the amount on Form 8962, line 24, is zero or blank                       leave Form 8962, line 28, blank and enter the amount from line 27 on line 29.
you didn’t receive the benefit of advance monthly payments of the HCTC   leave Form 8962, line 28, blank and enter the amount from line 27 on line 29.
the amount on Form 8962, line 24, is greater than zero                   after you complete Form 8962, line 27, complete Form 8885. 
                                                                          
and                                                                      If you aren’t instructed to complete the Excess Advance HCTC Repayment Worksheet 
                                                                         for Form 8885, line 5, add the amount from Form 8885, line 5, if any, to the applicable 
you received the benefit of advance monthly payments of the HCTC for     repayment limitation provided in the instructions for Form 8962, line 28. Enter the result 
at least 1 month of the year for individual(s) who were enrolled in a    on Form 8962, line 28, and complete Form 8962, line 29.
qualified health plan offered through a Marketplace for at least 1 other  
month of the year                                                        If you are instructed to complete the Excess Advance HCTC Repayment Worksheet for 
                                                                         Form 8885, line 5, complete only lines 1 and 2 of the worksheet and do one of the 
                                                                         following.
                                                                          (1) If line 1 of the worksheet is greater than or equal to line 2 of the worksheet:
                                                                              (a)  Complete line 3 of the worksheet and enter the amount on Form 8885, line 5, 
                                                                                   and Schedule 3 (Form 1040), 1040-SS, or 1040-PR, as instructed;
                                                                              (b)  On Form 8962, line 28, enter the sum of the amount on Form 8885, line 5, 
                                                                                   and the applicable repayment limitation provided in the instructions for Form 
                                                                                   8962, line 28; and
                                                                              (c)  Complete Form 8962, line 29.
                                                                          (2) If line 1 of the worksheet is less than line 2 of the worksheet:
                                                                              (a)  Complete Form 8962, lines 28 and 29, using the applicable repayment 
                                                                                   limitation provided in the Instructions for Form 8962 without any 
                                                                                   adjustments; and
                                                                              (b)  Using this information, complete lines 4 through 7 of the worksheet as 
                                                                                   instructed.
                                                                          See the Excess Advance HCTC Repayment Worksheet for details.

Instructions for Form 8885 (2020)                                             -3-

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the coverage listed under item 3, 4a, or 4e Example 1. You checked January on
Specific Instructions in the definition of Qualified Health line 1. You paid $225 ($200 for basic
Insurance Coverage, earlier) and the coverage and $25 for dental benefits
Line 1 employer paid any part of the cost of the which are purchased separately) directly
You must elect the HCTC to receive the coverage. to your health plan for your January
coverage. The $25 you paid for dental
benefit of the HCTC. Check the box for the Any amounts contributed to the benefits is ineligible for the HCTC. You
first eligible coverage month you are ! cost of coverage by you or your would include the $200 you paid for your
electing to take the HCTC. All of the CAUTION spouse on a pre-tax basis are
basic insurance on line 2.
statements listed on the form, and as considered to have been paid by the
further explained in these instructions, employer. Example 2. You checked December
must be true as of the first day of that on line 1. You participated in the advance
month. You must also check the box for Example. You had health insurance monthly payment program and paid only
each month after the election month for coverage under an employer-sponsored $88 (27.5%) of your $320 December
which all of the statements listed on the health insurance plan as of October 1. The premium to “US Treasury-HCTC.” You
form are true as of the first day of that employer paid 40% of the cost of the received a Form 1099-H showing an
month, even if you aren’t claiming the coverage. You paid 60% of the cost of the advance payment of $232 (72.5% of the
HCTC for those months. coverage through pre-tax contributions. $320 premium) for your December
Employer-sponsored health insurance You can’t take the HCTC for the month of coverage. You wouldn’t include any part of
coverage. Don’t check the box for any October because the employer is the December coverage premium on line 2
month that, as of the first day of the month, considered to have paid 100% of the cost because you already received the benefit
either (1) or (2) applies. of the coverage. of the advance monthly payment program
for December. You must still file Form
1. You were covered under any Line 2 8885 to elect the HCTC for December.
employer-sponsored health insurance
plan (including any employer-sponsored If your qualified health insurance Line 5
health insurance plan of your spouse) ! coverage covers anyone other If the resulting amount from line 5 is
(except insurance substantially all of the CAUTION than you and your qualifying
coverage of which is of excepted benefits family members, see Pub. 502, Medical negative, zero, or blank, you can’t claim
described in section 9832(c)) and the and Dental Expenses, before completing the HCTC on your income tax return.
employer paid 50% or more of the cost of line 2 to determine which amounts are However, you must still file Form 8885 to
the coverage. considered to be paid for coverage for you elect the HCTC for any months you
2. You were an eligible ATAA or and your qualifying family members. participated in the advance monthly
payment program.
RTAA recipient and either of the following Enter the total amount of insurance
applies. premiums paid by you for coverage for You received an excess advance
a. You were eligible for qualified you and all qualifying family members monthly payment of the HCTC if you
health insurance coverage (including any under Qualified Health Insurance received the benefit of an advance
employer-sponsored health insurance Coverage, earlier, for all eligible coverage monthly payment for any month not
plan of your spouse) (other than the months checked on line 1. But don’t checked on line 1 (see Form 1099-H) or
coverage listed under item 3, 4a, or 4e in include any insurance premiums paid by received a reimbursement of the HCTC
the definition of Qualified Health Insurance you to “US Treasury-HCTC.” Also, don’t during the year by filing Form 14095 for
Coverage, earlier) where the employer include any advance monthly payments any month not checked on line 1. You
would have paid 50% or more of the cost your health plan administrator received must reduce the amount on line 5 by the
of the coverage. from the IRS, as shown on Form 1099-H, total of these payments. Use the Excess
b. You were covered under any box 1, or any insurance premiums you Advance HCTC Repayment Worksheet to
qualified health insurance coverage paid for which you received a figure the amount of the excess advance
(including any employer-sponsored health reimbursement of the HCTC during the monthly payment that you must repay.
insurance plan of your spouse) (other than year by filing Form 14095.

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Excess Advance HCTC Repayment Worksheet—Line 5
1. Multiply the amount from Form 8885, line 4, by 72.5% (0.725) 1.
2. Enter the total advance monthly payments of the HCTC made on your behalf for coverage for any month not checked on Form 8885, line 1 (see
Form 1099-H) and reimbursements of the HCTC you received by filing Form 14095 for any month not checked on Form 8885, line 1. If line 2 is
greater than line 1, skip line 3 and go to line 4 2.
3. Subtract line 2 from line 1. Enter the result here and on:
• Form 8885, line 5; and
• Schedule 3 (Form 1040), line 12c; Form 1040-SS, line 10; or Form 1040-PR, line 10.
Don’t complete the rest of this worksheet 3.
4. Subtract line 1 from line 2. Enter the result here 4.
5. Consider all the individual(s) covered under the health insurance coverage for which you received the benefit of the advance monthly payments
of the HCTC during the year. Were any of those individual(s) also enrolled in a qualified health plan offered through a Marketplace for at least 1
other month of the year?
• Yes. Complete Form 8962 using the special instructions under Participants in a Health Insurance Marketplace, earlier. Go to line 6.
• No. Skip line 6. Enter the amount from line 4 on line 7.
6. Is the amount on Form 8962, line 5, less than 400 AND the amount on Form 8962, line 24, greater than zero?

• Yes. IF . . . THEN enter on line 6 . . .
Form 8962, line 28, is blank the sum of Form 8962, line 26, and the
applicable repayment limitation provided in the
instructions for Form 8962, line 28.
Form 8962, line 28, isn’t blank Form 8962, line 28, reduced by Form 8962,
line 29.
Note. If you are married filing jointly and both you and your spouse must file Forms 8885, one spouse should
figure their repayment limitation on line 6 of this worksheet. If line 6 is greater than line 7, enter the difference
on line 6 of the second spouse’s worksheet. Otherwise, enter zero on lines 6 and 7 of the second spouse’s
worksheet.
• No. Leave line 6 blank. Enter the amount from line 4 on line 7. 6.
7. If you entered an amount on line 6, enter the smaller of line 4 or line 6 here. Also enter the items below where indicated.

IF you’re filing . . . THEN include the amount on AND enter “HCTC” and the amount on line 7 . . .
line 7 in the total entered on . . .
Form 1040, 1040-SR, or line 16 in the space next to box on line 16; then check box .3 3
1040-NR
Form 1040-SS or 1040-PR line 6 on the dotted line next to line 6.
Then, on Form 8885, line 5, enter the line 7 amount as a negative number by enclosing it in parentheses 7.

Required Documents • For PBGC eligibility—A copy of the premium includes amounts that don’t
If you claim any HCTC on line 5, you must official letter or a copy of your 2020 Form count towards the HCTC, such as dental
provide verifiable proof for each month 1099-R, Distributions From Pensions, or vision coverage or coverage for family
you are claiming the credit on line 2 that Annuities, Retirement or Profit-Sharing members who aren’t eligible for the HCTC,
your health insurance coverage is Plans, IRAs, Insurance Contracts, etc., your documentation must also specify
qualified health insurance coverage for the from the PBGC showing you received a those ineligible amounts.
HCTC and that you paid premiums for the benefit paid by the PBGC. 3. Proof of payment for each month
qualified health insurance coverage by 2. A copy of your health insurance you are claiming the credit on line 2 such
attaching the documents listed below to bills or COBRA payment coupons for each as:**
your Form 8885. No documents are month you are claiming the credit on a. Canceled checks (copy of front and
required if you file Form 8885 only to elect line 2.* The bills must have: back),
the HCTC for months you participated in a. Your name (or name of the policy b. Bank statements,
the advance monthly payment program. holder),
c. Credit card statements, or
All health plans. For all health plans, b. The name of your health plan,
d. Money orders.
you must include all of the following c. Your monthly premium amount,
documents. d. Dates of coverage, and **Your proof of payment must indicate
the amount paid and to whom it was paid.
1. An official letter reflecting that you e. Your health plan identification If you don’t have one of these types of
were an eligible individual for the months number(s). proof of payment, contact your health plan
claimed on line 2 in 2020.
• For trade-certified individuals *If your health plan doesn’t provide for a record of your payment(s).
demonstrating TAA, ATAA, or RTAA members with an insurance bill or COBRA COBRA coverage. You must include
eligibility—A copy of the official letter from payment coupon, you must provide health the information under All health plans,
the Department of Labor, your state plan enrollment documents or an official earlier, and one of the following
workforce agency, or employment office letter from your health plan that has the documents.
stating you are eligible for trade required information listed under items 2a
adjustment benefits. through 2e above. If your monthly 1. A copy of your completed and
signed COBRA Election Letter. It may also

Instructions for Form 8885 (2020) -5-

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be called a COBRA Enrollment Form, employer contributed less than 50% of the showing an advance payment of $543.75
Application Form, Enrollment Application cost of the coverage (TAA recipients and for your July coverage. You would include
for Continuing Coverage, or Election PBGC payees) or made no contributions the $750 you paid for your June coverage
Agreement. to the cost of coverage (ATAA and RTAA on line 2. You wouldn’t include any part of
2. A letter from your former employer recipients). the July coverage premium on line 2
because you already received the benefit
or COBRA administrator saying you have E-filed return. If you e-file, you can of the advance monthly payment program
COBRA coverage. The letter must have: attach a copy of any required documents for July. You must attach copies of your
a. The COBRA coverage start and to an electronically filed return as a PDF if health insurance bills and proof of
end dates; your tax software supports it, or you must payment for the June coverage for you
b. Name of the health plan; attach those documents to Form 8453, and your qualifying family members
U.S. Individual Income Tax Transmittal for totaling $750, along with any other
c. Your home address; and an IRS e-file Return, and mail them to the required documents. You don’t need to
d. Covered family members, their IRS according to the instructions for that attach documents for your July coverage.
dates of birth, their relationship to you, and form.
their social security numbers. Example 2. You checked March and
Example 1. You checked June and April on line 1. Your insurance coverage
3. A copy of “Notice of Rights to July on line 1. Your insurance coverage for for each month costs $750 ($500 for you
Continue Coverage.” each month costs $750 ($500 for you and and $250 for your qualifying family
Coverage through your spouse’s $250 for your qualifying family members). members). You paid $750 directly to your
employer. You must include the You paid $750 directly to your health plan health plan for each month. You would
information under All health plans, earlier, for your June coverage. You then paid include $1,500 on line 2 for the March and
and the following documents. $206.25 (27.5% of the $750 premium) for April coverage. You must attach copies of
• Copies of paycheck stubs showing the your July coverage as part of the advance your health insurance bills and proof of
health coverage deductions for each monthly payment program. Your health payment for the March and April coverage
month you are claiming the credit on plan administrator received an advance for you and your qualifying family
line 2. payment of $543.75 (72.5% of the $750 members totaling $1,500 ($750 for each
• A letter or other statement from your premium) from the IRS for your July month), along with any other required
spouse’s employer that states the coverage. You received a Form 1099-H documents.

-6- Instructions for Form 8885 (2020)

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