OMB No. 1545-0074
                                            Health Coverage Tax Credit
Form  8885
                                   ▶
Department of the Treasury             Attach to Form 1040, 1040-SR, 1040-NR, 1040-SS, or 1040-PR.                             2021
                                                                                                                               Attachment 
Internal Revenue Service       ▶ Go to www.irs.gov/Form8885 for instructions and the latest information.                       Sequence No. 134
Name of recipient (if both spouses are recipients, complete a separate form for each spouse)                         Recipient’s social security number

Before you begin: See Definitions and Special Rules in the instructions.

        Do not complete this form if you can be claimed as a dependent on someone else’s 2021 tax return.
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CAUTION
Part I  Election To Take the Health Coverage Tax Credit
1     Check the box below for the first month in your tax year that you elect to take the Health Coverage Tax Credit (HCTC).                           All of
      the following statements must be true as of the first day of that month. You must also check the box for each month after your 
      election month that all of the following statements were true as of the first day of that month.
      • You were an eligible trade adjustment assistance (TAA) recipient, alternative TAA (ATAA) recipient, reemployment TAA (RTAA) 
      recipient, or Pension Benefit Guaranty Corporation (PBGC) payee; or you were a qualifying family member of an individual who 
      fell  under  one  of  the  categories  listed  above  when  he  or  she  passed  away  or  with  whom  you  finalized 
      a divorce. 
      • You and/or your family member(s) were covered by HCTC-qualified health insurance coverage for which you paid the entire 
      premiums, or your portion of the premiums, directly to your health plan or to “US Treasury-HCTC.”
      • You were not enrolled in Medicare Part A, B, or C, or you were enrolled in Medicare but your family member(s) qualified for 
      the HCTC.
      • You were not enrolled in Medicaid or the Children’s Health Insurance Program (CHIP).
      • You were         not enrolled in the Federal Employees Health Benefits Program (FEHBP) or eligible to receive benefits under the
      U.S. military health system (TRICARE).
      • You were not imprisoned under federal, state, or local authority.
      • Your or your spouse’s employer (or former employer) did not pay 50% or more of the cost of coverage.
      • You did not receive a 100% COBRA premium reduction from your former employer or COBRA administrator.

        January                February              March              April                            May               June
        July                   August                September          October                          November          December
Part II Health Coverage Tax Credit
2     Enter the total amount paid directly to your health plan for HCTC-qualified health insurance coverage for 
      the months checked on line 1. See instructions. Do not include on line 2 any insurance premiums paid 
      to “US Treasury-HCTC” or any advance monthly payments made on your behalf as shown on Form 
      1099-H  or  any  insurance  premiums  you  paid  for  which  you  received  a  reimbursement  of  the  HCTC 
      during the year by filing Form 14095  .    . . . .   .  . .     . .                    . . . . . . . . .       . . . 2
                 You must attach the required documents listed in the instructions for any amounts included 
      ▲!         on line 2. If you do not attach the required documents, your credit will be disallowed.
      CAUTION
3     Enter  the  total  amount  of  any  Archer  MSA  or  health  savings  accounts  distributions  used  to  pay  for 
      HCTC-qualified health insurance coverage for the months checked on line 1  .                 . . . . . .       . . . 3
4     Subtract line 3 from line 2. Enter the result, but not less than zero  .                 . . . . . . . .       . . . 4
5     Health Coverage Tax Credit.     If you received the benefit of the advance monthly payment program
      for any month not checked on line 1 or received a reimbursement of the HCTC during the year by
      filing Form 14095 for any month not checked on line 1, see the instructions for line 5 for more details. 
      Otherwise, multiply the amount on line 4 by 72.5% (0.725). Enter the result here and on Schedule 3
      (Form 1040), line 13c; Form 1040-SS, line 10; or Form 1040-PR, line 10  .                    . . . . . .       . . . 5 
For Paperwork Reduction Act Notice, see your tax return instructions.                                Cat. No. 34641D           Form 8885 (2021)