Enlarge image
OMB No. 1545-0074
Form 8962 Premium Tax Credit (PTC)
▶
Department of the Treasury Attach to Form 1040, 1040-SR, or 1040-NR. 2021
Attachment
Internal Revenue Service ▶ Go to www.irs.gov/Form8962 for instructions and the latest information. Sequence No. 73
Name shown on your return Your social security number
A. If you, or your spouse (if filing a joint return), received, or were approved to receive, unemployment compensation for any week beginning during 2021,
check the box. See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ▶
B. You cannot take the PTC if your filing status is married filing separately unless you qualify for an exception. See instructions. If you qualify, check the box ▶
Part I Annual and Monthly Contribution Amount
1 Tax family size. Enter your tax family size. See instructions . . . . . . . . . . . . . . . . . 1
2a Modified AGI. Enter your modified AGI. See instructions . . . . . . . . . 2a
b Enter the total of your dependents’ modified AGI. See instructions . . . . . . 2b
3 Household income. Add the amounts on lines 2a and 2b. See instructions . . . . . . . . . . . . 3
4 Federal poverty line. Enter the federal poverty line amount from Table 1-1, 1-2, or 1-3. See instructions. Check the
appropriate box for the federal poverty table used. a Alaska b Hawaii c Other 48 states and DC 4
5 Household income as a percentage of federal poverty line (see instructions) . . . . . . . . . . . . 5 %
6 Reserved for future use . . . . . . . . . . . . . . . . . . . . . . . . . . .
7 Applicable figure. Using your line 5 percentage, locate your “applicable figure” on the table in the instructions . . 7
8 a Annual contribution amount. Multiply line 3 by b Monthly contribution amount. Divide line 8a
line 7. Round to nearest whole dollar amount 8a by 12. Round to nearest whole dollar amount 8b
Part II Premium Tax Credit Claim and Reconciliation of Advance Payment of Premium Tax Credit
9 Are you allocating policy amounts with another taxpayer or do you want to use the alternative calculation for year of marriage? See instructions.
Yes. Skip to Part IV, Allocation of Policy Amounts, or Part V, Alternative Calculation for Year of Marriage. No. Continue to line 10.
10 See the instructions to determine if you can use line 11 or must complete lines 12 through 23.
Yes. Continue to line 11. Compute your annual PTC. Then skip lines 12–23 No. Continue to lines 12–23. Compute
and continue to line 24. your monthly PTC and continue to line 24.
(a) Annual enrollment (b) Annual applicable (c) Annual (d) Annual maximum (e) Annual premium tax (f) Annual advance
Annual premiums (Form(s) SLCSP premium contribution amount premium assistance credit allowed payment of PTC (Form(s)
Calculation 1095-A, line 33A) (Form(s) 1095-A, (line 8a) (subtract (c) from (b); if (smaller of (a) or (d)) 1095-A, line 33C)
line 33B) zero or less, enter -0-)
11 Annual Totals
(a) Monthly enrollment (b) Monthly applicable (c) Monthly
Monthly premiums (Form(s) SLCSP premium contribution amount (d) Monthly maximum (e) Monthly premium tax (f) Monthly advance
Calculation 1095-A, lines 21–32, (Form(s) 1095-A, lines (amount from line 8b premium assistance credit allowed payment of PTC (Form(s)
column A) 21–32, column B) or alternative marriage (subtract (c) from (b); if (smaller of (a) or (d)) 1095-A, lines 21–32,
monthly calculation) zero or less, enter -0-) column C)
12 January
13 February
14 March
15 April
16 May
17 June
18 July
19 August
20 September
21 October
22 November
23 December
24 Total premium tax credit. Enter the amount from line 11(e) or add lines 12(e) through 23(e) and enter the total here 24
25 Advance payment of PTC. Enter the amount from line 11(f) or add lines 12(f) through 23(f) and enter the total here 25
26 Net premium tax credit. If line 24 is greater than line 25, subtract line 25 from line 24. Enter the difference here and
on Schedule 3 (Form 1040), line 9. If line 24 equals line 25, enter -0-. Stop here. If line 25 is greater than line 24,
leave this line blank and continue to line 27 . . . . . . . . . . . . . . . . . . . . . 26
Part III Repayment of Excess Advance Payment of the Premium Tax Credit
27 Excess advance payment of PTC. If line 25 is greater than line 24, subtract line 24 from line 25. Enter the difference here 27
28 Repayment limitation (see instructions) . . . . . . . . . . . . . . . . . . . . . . 28
29 Excess advance premium tax credit repayment. Enter the smaller of line 27 or line 28 here and on Schedule 2
(Form 1040), line 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
For Paperwork Reduction Act Notice, see your tax return instructions. Cat. No. 37784Z Form 8962 (2021)
