Form 8885
Form 8885
Department of the Treasury
Internal Revenue Service
Health Coverage Tax Credit
▶
Attach to Form 1040, Form 1040NR, Form 1040-SS, or Form 1040-PR.
▶
Information about Form 8885 and its instructions is at www.irs.gov/form8885.
OMB No. 1545-0074
2016
Attachment
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.
▲
!
CAUTION
Do not complete this form if you can be claimed as a dependent on someone else’s 2016 tax return.
Part IElection 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.
• 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.
JanuaryFebruaryMarchAprilMayJune
JulyAugustSeptemberOctoberNovemberDecember
Part IIHealth 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 on coverage for which you received the benefit of the advance monthly payment program
2
▲
!
CAUTION
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.
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
4Subtract line 3 from line 2. Enter the result, but not less than zero ...........
4
5
Health Coverage Tax Credit. Multiply the amount on line 4 by 72.5% (0.725). Enter the result
here and on Form 1040, line 73 (check box c); Form 1040NR, line 69 (check box c); 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 (2016)
THIS PAGE INTENTIONALLY LEFT BLANK
