Get Irs 14095 2017

The IRS 14095 form is used to request a Health Coverage Tax Credit (HCTC) reimbursement for premiums paid to a qualified health plan. This guide provides a clear, step-by-step approach for completing the form online, ensuring you have the necessary information and documents to facilitate a successful submission.

Follow the steps to successfully complete your IRS 14095 reimbursement request.

1. Click the ‘Get Form’ button to obtain the IRS 14095 form and open it in your document editor.
2. In Part 1, provide your personal information. Fill in your full name, last four digits of your social security number, mailing address, city, state, ZIP code, telephone number, and HCTC participant identification number if applicable.
3. In Part 2, determine your eligibility and request reimbursement. Check the boxes for each month you are requesting reimbursement. Confirm your eligibility based on the criteria outlined, ensuring you confirm that you have made the necessary payments directly to a qualified health plan.
4. Calculate the total amounts as instructed. Enter the total amount paid for qualified premiums and any other specified amounts, including those related to dental or vision benefits. Complete all calculations as required.
5. In Part 3, gather and prepare supporting documents. Ensure you include health insurance bills or payment evidence that includes your name, the health plan name, coverage dates, and proof of your premium payments.
6. Complete Part 4 by signing and dating the form, certifying that the information provided is accurate and truthful. Ensure that all required attachments are included when submitting the form.
7. After reviewing your completed form and attachments, save your changes. You can then download, print, or share the form as needed prior to submission.

Start filling out your IRS 14095 form online today to ensure your reimbursement request is submitted promptly.