Department of the Treasury - Internal Revenue Service
Form 14765 
(May 2021)                                        Employee Premium Tax Credit (PTC) Listing 
Any month not highlighted is a month that the employee received a PTC and no safe harbor or other relief from the ESRP was applicable. The employee is an assessable full-time 
employee for that month. Any month that shows XF, XG, or XH is due to a determination that you do not qualify for the safe harbor being claimed (2F, 2G, or 2H). If you still think the 
safe harbor applies, you may provide your computation with your written request for reconsideration.
Employer name                                                                                               Employer ID number     Tax year

                              All 12 months
Employee Name         SSN     Indicator                                                                                                        Additional 
     (last, first)    (last 4 Codes           Jan Feb Mar Apr May                                   Jun Jul Aug Sep            Oct Nov     Dec Information 
                      digits) (Form 1095-C,                                                                                                    Attached
                              lines 14 and 16 
                              combined)

Catalog Number 68863V                                     www.irs.gov                                                              Form 14765 (Rev. 5-2021)