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Official form guide
Form 14095: The Health Coverage Tax Credit (HCTC) Reimbursement Request
Internal Revenue Service Form 14095 is the Health Coverage Tax Credit (HCTC) Reimbursement Request used by eligible HCTC AMP participants to claim reimbursement for qualified health‑plan premiums paid directly in the current calendar year. The IRS must receive the form on or before September 30.
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IRS Form 14095 - The Health Coverage Tax Credit (HCTC) Reimbursement Request
Internal Revenue Service Form 14095 is the Health Coverage Tax Credit (HCTC) Reimbursement Request used by eligible HCTC AMP participants to claim reimbursement for qualified health‑plan premiums paid directly in the current calendar year. The IRS must receive the form on or before September 30.
Risk Radar
Scan points- 1Missing the September 30 filing deadline disqualifies the reimbursement request.
- 2Submitting the form after September 30 of the current calendar year.
- 3Failing to attach health‑plan bills that prove payment for each requested month.
- 4Claiming reimbursement for a month where the employer paid 50 % or more of coverage cost.
- 5Omitting the HCTC participant identification number from Part 1.
Plain English
Form 14095 lets you ask the IRS to pay back health‑insurance premiums you paid yourself while you were eligible for the Health Coverage Tax Credit but not in the AMP program. You list the months you paid, show the bills, and sign a statement that the information is true.
Submission Date
- Filing date: 2020-08-24 22:10:28
- Preparation window: collect IDs, supporting records, and signatures in advance.
- Final review: verify names, dates, and required fields before submission.
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What this form is for
- Use this form when you are eligible for the HCTC AMP program, paid premiums directly to a qualified health plan in the current calendar year, and were not enrolled in the HCTC AMP program for the coverage month.
- Do not use it when you were enrolled in the HCTC AMP program for the month, when the employer paid 50 % or more of the coverage cost, or when you are requesting reimbursement for months outside the current calendar year.
- Check Form 8885 instead when you want to claim the Health Coverage Tax Credit on your federal tax return rather than request a reimbursement.
Form selector
Use this form or another form?
Requesting reimbursement for premiums paid in a prior calendar year
Reimbursement not allowed; credit must be claimed on tax return
✓ Confirm the payment year is before the current calendar year
Want to claim the Health Coverage Tax Credit on your tax return instead of a reimbursement
This form is used to claim the credit on your tax return
✓ Verify you are filing the credit on your tax return
Need to correct a denied reimbursement request
You must submit a new request or appeal using the same form
✓ Ensure you address the denial reasons before resubmitting
Deadline or filing window
You may file Form 14095 once you have paid qualified premiums directly to a health plan during the current calendar year while eligible for the HCTC AMP program. The completed form must be received by the IRS on or before September 30 of that year. No extension is provided in the official instructions.
Checklist
What you need before filling it out
Part 1: Personal information
Name, SSN, mailing address, phone, HCTC participant ID · Form 14095 Part 1 fields
Part 2: Eligibility statements
Employer did not pay ≥50 % of coverage; not claimed as dependent · Form 14095 Part 2 statements
Monthly reimbursement selection
Checked boxes for months you paid premiums · Part 3 month checkboxes
Supporting documents
Canceled checks, bank statements, credit‑card statements, or money‑order receipts showing amount and payee; health‑plan qualification documents · Attachments to Form 14095
Health plan details
Plan name, monthly premium amount, dates of coverage, plan ID numbers (member, group, policy) · Bullet list on Form 14095 page 2
Before you submit
- 1Print or type all responses on Form 14095.
- 2Complete every part of the form, including Part 1 through Part 5.
- 3Attach verifiable proof that the health plan is qualified and that premiums were paid.
- 4Include canceled checks, bank statements, credit‑card statements, or money‑order receipts showing amount and payee.
- 5Check the month boxes only for eligible months in the current calendar year.
- 6Sign and date the form in Part 5.
- 7Mail the completed form and attachments to the IRS address provided.
- 8Ensure the IRS receives the form on or before September 30 of the current calendar year.
- 9Verify you are eligible for the HCTC AMP program in each requested month.
- 10Include your HCTC participant identification number from Letter 4545.
How to file this form
- 1Print or type the completed Form 14095.
- 2Gather and attach required supporting documents proving qualified health plan and premium payments.
- 3Check the month boxes for eligible current‑year months and verify eligibility statements.
- 4Sign and date the form in Part 5.
- 5Mail the form and attachments to Internal Revenue Service Stop 6098 AUSC, Austin, TX 78741.
- 6Retain a copy of the mailed package as proof of filing.
Known limitations
- 1Only months in the current calendar year are eligible for reimbursement.
- 2Only premiums paid directly to a qualified health plan qualify; dental or vision benefits are excluded.
- 3Request is considered only if you were eligible for the HCTC AMP program in the coverage month and made at least one premium payment through the program in the current calendar year.
- 4Payments made in prior calendar years cannot be reimbursed via this form; they must be claimed on Form 8885.
- 5The IRS must receive the completed form on or before September 30 of the current calendar year.
Field map
Compact field-by-field guide
General Info
2 items
Full legal name and taxpayer identification number (SSN or EIN).
Current mailing address.
Details
2 items
Complete all applicable sections of this form according to the official IRS instructions.
Enter the relevant dollar amount if this form involves tax calculation.
Certification
1 items
Read and acknowledge any certifications required by this form.
Signatures
1 items
Sign and date. Unsigned forms cannot be processed.
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Fillable formOpen in Editor->Form 14095 is revised August 2020 (Rev. 8‑2020); the source does not indicate a newer version.
What changed or needs a fresh check
- Edition date — confirm the revision reads 8‑2020
- Fee — Not stated in the official source
- Mailing address — confirm mail to Internal Revenue Service Stop 6098 AUSC Austin, TX 78741
- Signature — confirm signature and date are provided on Part 5
- Eligibility proof — confirm you attach required supporting documents
- Deadline — confirm IRS receives the form on or before September 30 of the current calendar year
Quick Facts
Downloads
After you file
- 1Keep a copy of the completed Form 14095 and all attached supporting documents.
- 2Retain the supporting documents (bills, proof of payment) as long as they may become material for tax administration.
- 3Expect the reimbursement to be issued within up to 12 weeks after the IRS receives the form, provided all requirements are met.
- 4If the request is denied, review the denial letter for the reason and consider submitting a corrected Form 14095.
Sources
- SRCForm p.1 — eligibility requires participation in HCTC AMP program in coverage month and at least one premium payment in current calendar year.
- SRCForm p.1 — reimbursement request must be received by IRS on or before September 30 of the current calendar year.
- SRCForm p.2 — only months during the current calendar year are eligible for reimbursement request.
- SRCForm p.2 — dental or vision benefits do not qualify for the HCTC.
- SRCForm p.2 — acceptable proof of payment includes canceled checks, bank statements, credit card statements, money order receipts.
- SRCForm p.1 — mailing address: Internal Revenue Service Stop 6098 AUSC Austin, TX 78741.
- SRCForm p.1 — processing time up to 12 weeks after receipt if all requirements are met.
- SRCForm p.1 — if request not approved, the HCTC Program will send a denial letter.
Common confusion points
Can I request reimbursement for premiums I paid last year?
The form only covers premiums paid in the current calendar year.
→ Verify the payment month is within the current calendar year.
Do dental or vision premiums count toward my reimbursement?
Dental and vision benefits are explicitly excluded from HCTC eligibility.
→ Ensure the premium is for qualified health plan coverage, not dental or vision.
Do I have to be enrolled in the HCTC AMP program to get reimbursed?
The form is for participants who were eligible but not enrolled in the AMP program.
→ Confirm you were eligible for HCTC AMP in the coverage month and not enrolled.
What documents prove I paid the premiums?
The IRS requires specific proof of payment.
→ Attach canceled checks, bank statements, credit card statements, or money order receipts showing amount and payee.
Where should I mail my completed Form 14095?
The mailing address is provided in the instructions.
→ Send the form to Internal Revenue Service Stop 6098 AUSC, Austin, TX 78741.
What is the deadline to submit my reimbursement request?
The form must be received by the IRS by September 30 of the current calendar year.
→ Mail the form so it arrives on or before September 30.
Workflow map
Related forms and next steps
Before
Current
After
Often used with
⚠ If something goes wrong
- Form 14095 – you will receive a denial letter explaining why the request was denied.
Questions about IRS Form 14095
What is IRS Form 14095 used for?
Form 14095 lets you ask the IRS to pay back health‑insurance premiums you paid yourself while you were eligible for the Health Coverage Tax Credit but not in the AMP program. You list the months you paid, show the bills, and sign a statement that the information is true.
Who must file IRS Form 14095?
Eligible participants in the Health Coverage Tax Credit Advanced Monthly Payment (AMP) program who paid premiums directly to a qualified health plan while not enrolled in the AMP must file IRS Form 14095.
What information does IRS Form 14095 require?
The form collects personal data in Part 1, eligibility statements in Part 2, month selections in Part 3, total premium calculations on lines 1‑6 in Part 4, and a signed certification in Part 5.
When is IRS Form 14095 due?
The IRS must receive Form 14095 on or before September 30 of the current calendar year.
Where do I file IRS Form 14095?
Mail the completed form and supporting documents to Internal Revenue Service Stop 6098 AUSC, Austin, TX 78741.
How do I complete IRS Form 14095?
Print or type the form, complete Part 1 with your personal information, answer the eligibility questions in Part 2, check each month you are requesting reimbursement in Part 3, calculate totals on lines 1‑6 of Part 4, attach health‑plan bills, sign and date Part 5, then mail it to the IRS address before the deadline.
What happens if IRS Form 14095 is filed incorrectly?
A false statement on the form can result in disqualification from the HCTC AMP program.
Can I request reimbursement for premiums I paid last year?
The form only covers premiums paid in the current calendar year. Verify the payment month is within the current calendar year.
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