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Official form guide
Form 14095: The Health Coverage Tax Credit (HCTC) Reimbursement Request
Treasury - Internal Revenue Service Form 14095 is The Health Coverage Tax Credit (HCTC) Reimbursement Request, used to request reimbursement for premiums paid directly to a qualified health plan; the IRS can consider requests if made on or before September 30 of the current calendar year.
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IRS Form 14095 - The Health Coverage Tax Credit (HCTC) Reimbursement Request
Treasury - Internal Revenue Service Form 14095 is The Health Coverage Tax Credit (HCTC) Reimbursement Request, used to request reimbursement for premiums paid directly to a qualified health plan; the IRS can consider requests if made on or before September 30 of the current calendar year.
Risk Radar
Scan points- 1Failing to mail Form 14095 by September 30 of the current calendar year may result in denial.
- 2Failing to provide verifiable proof that your health plan is qualified for HCTC and payment was made.
- 3Requesting reimbursement for months outside of the current calendar year.
- 4Not ensuring all Part 2 requirements are true on the first day of each requested month.
- 5Forgetting to check the box in Part 3 for every month you seek reimbursement for.
Plain English
This form allows individuals to ask the Internal Revenue Service (IRS) to pay back money they spent paying for health insurance premiums. You use it when you were eligible for the HCTC but didn't sign up for the Advanced Monthly Payment program. If approved, the IRS will reimburse you for those payments.
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 requesting reimbursement for premiums paid directly to a qualified health plan for any month in the current calendar year while eligible for but not enrolled in the HCTC Advanced Monthly Payment (AMP) program.
- Do not use it when you were already enrolled in the HCTC AMP program and are simply claiming credit for payments made through that program; instead, check eligibility first.
- Check Form 8885 instead when claiming a HCTC credit on your federal tax return for amounts that cannot be reimbursed by this request.
Form selector
Use this form or another form?
Claiming prior year premiums
You may claim amounts from months before the current calendar year on this form's associated tax return.
✓ Confirm you are using Form 14095 to support your Form 8885 filing.
Requesting reimbursement for a specific month
You must check the box corresponding to that single month on Part 3 of Form 14095.
✓ Ensure all requirements listed in Part 2 are met for that checked month.
Submitting documentation without payment proof
The IRS requires verifiable proof that you paid the premiums, not just enrollment documents.
✓ Verify your attachment includes a canceled check copy or bank statement showing the amount paid.
Deadline or filing window
The request must be received by the IRS on or before September 30 of the current calendar year. If all requirements are met, reimbursement can take up to 12 weeks after mailing. No specific extension date is stated for the filing deadline itself.
Checklist
What you need before filling it out
Monthly Premium Amount
Canceled check copy / Bank statement / Credit card statement / Money Order receipt · Part 2, Item (Specific Month)
Health Plan Identification Number(s)
Health plan enrollment documents or official letter from health plan · Part 2, Item (Specific Month)
Your Name / Policy Holder Name
Your name or policy holder's name · Part 1 / Part 2 Header
HCTC Participant ID Number
Letter 4545 · Part 1, Item (Specific Field)
Proof of Payment
Canceled checks (copy of front and back) · Part 2 / Attachment Section
Before you submit
- 1Complete all parts of Form 14095.
- 2Provide verifiable proof that your health plan is qualified for the Health Coverage Tax Credit.
- 3Attach required supporting documents proving you paid the qualified health insurance premiums.
- 4Ensure you have checked the box(es) in Part 3 corresponding to the months you are requesting reimbursement for.
- 5Verify on Part 2 that for each requested month, your employer did not pay 50% or more of the coverage cost.
- 6Confirm on Part 2 that you cannot be claimed as a dependent on someone else’s federal income tax return for the requested month(s).
- 7Sign and date Form 14095 under penalties of perjury.
How to file this form
- 1Print or type your responses onto Form 14095.
- 2Complete Part 1 with your personal information, including your HCTC participant identification number from Letter 4545.
- 3Check the box(es) in Part 3 for every month of the current calendar year you wish to claim reimbursement for, ensuring all Part 2 criteria are met for those months.
- 4Attach required supporting documents (like canceled checks or bank statements) that verify payment for each requested month.
- 5Sign and date Form 14095 under penalties of perjury in Part 5.
- 6Mail the completed Form 14095 and all attachments to Internal Revenue Service Stop 6098, AUSC, Austin, TX 78741 before September 30 of the current calendar year.
Known limitations
- 1The IRS can consider a request for Form 14095 only if the filer was eligible to participate in the HCTC Advanced Monthly Payment (AMP) program during the coverage month being requested.
- 2A request will be considered only if the filer has made at least one premium payment through the HCTC AMP program in the current calendar year.
- 3Benefits for dental or vision do not qualify for reimbursement under Form 14095, even if paid to a qualified health plan.
- 4Only months during the current calendar year are eligible for reimbursement request on this form.
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->The current edition is dated August 2020 (Rev. 8-2020). The source does not direct the reader to a separate page for the absolute latest information, but it indicates this form governs the request.
What changed or needs a fresh check
- Edition date — confirm the revision date reads August 2020 (Rev. 8-2020).
- Fee — Not stated in the official source.
- Mailing address — confirm the IRS stop is Stop 6098, AUSC, Austin, TX 78741.
- Signature — ensure you provide your full name (print or type) and sign it.
- Eligibility requirement — confirm that your employer did not pay 50% or more of coverage cost for the requested month.
Quick Facts
Downloads
After you file
- 1Retain a copy of the completed and signed Form 14095.
- 2Keep copies of all required supporting documents attached to Form 14095.
- 3Expect a letter from the HCTC Program if your request is not approved, which will explain the denial reason.
- 4If reimbursement is denied, any amount that could not be reimbursed may be used to claim a HCTC credit on federal tax return (referencing Instructions for Form 8885).
- 5Allow up to 12 weeks for reimbursement processing time if all requirements are met.
Sources
- SRCForm 14095 (Rev. 8-2020) is the official title, used to request reimbursement for premiums paid directly to a qualified health plan. (Forms p.1)
- SRCThe IRS can consider the request if it was made on or before September 30 of the current calendar year. (Instructions p.1)
- SRCIf your request is not approved, the HCTC Program will send a letter explaining why the request was denied. (Instructions p.1)
- SRCTotal Requested Reimbursement is calculated by multiplying Line 5 (Net Total Paid) by 72.5% (0.725). (Form p.2)
- SRCSupporting documents must show your name, health plan name, monthly premium amount, dates of coverage, and the policy holder's SSN if different from the requester. (Part 4, Form p.2)
- SRCAcceptable proof of payment includes canceled checks (copy of front and back), bank statements, credit card statements, or money order receipts. (Part 4, Form p.2)
Common confusion points
What is the difference between an eligible month and a payment made before the current year?
The form only covers months in the current calendar year, but what about payments from prior years?
Payments from prior years may be claimed on your federal tax return for that specific year (see Form 8885 Instructions).
→ Confirm you are using this form to request reimbursement for a month *in* the current calendar year.
What is the difference between total paid and total requested reimbursement?
Line 1 is 'total amount paid directly to your qualified health plan,' but Line 3 subtracts dental/vision.
The final calculation (Line 5 minus Line 4) determines the net amount eligible for HCTC.
What documents are acceptable proof of payment?
Acceptable proofs include copies of canceled checks (front and back), bank statements, credit card statements, or money order receipts.
Always ensure the proof shows the amount paid and to whom it was paid.
If my health plan doesn't provide a bill, what do I submit instead?
Provide health plan enrollment documents or an official letter from your health plan that lists all required information.
Workflow map
Related forms and next steps
Before
Current
After
Often used with
⚠ If something goes wrong
- The HCTC Program will send a letter explaining denial — This correspondence explains why Form 14095 was not fully accepted.
Questions about IRS Form 14095
What is IRS Form 14095 used for?
This form allows individuals to ask the Internal Revenue Service (IRS) to pay back money they spent paying for health insurance premiums. You use it when you were eligible for the HCTC but didn't sign up for the Advanced Monthly Payment program. If approved, the IRS will reimburse you for those payments.
Who must file IRS Form 14095?
Individuals who paid qualified health insurance premiums directly to a qualified health plan while being eligible for the HCTC AMP program must file this form with the Internal Revenue Service.
What information does IRS Form 14095 require?
Part 1 collects personal information about the filer. Part 2 confirms eligibility requirements for each month. Parts 3 and 4 detail which months are requested and lists the total amounts paid, including dental/vision benefits.
When is IRS Form 14095 due?
The IRS must receive Form 14095 on or before September 30 of the current calendar year to consider the request.
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?
First, complete Part 1 with personal details. Then, check the months in Part 3 and ensure all Part 2 requirements are met for those months. Finally, fill out the totals on Page 2 (Part 2) and sign/date in Part 5.
What happens if IRS Form 14095 is filed incorrectly?
An amount that cannot be reimbursed on Form 14095 may still be used to claim a HCTC credit when filing your federal tax return (see Instructions for Form 8885).
The form only covers months in the current calendar year, but what about payments from prior years?
Payments from prior years may be claimed on your federal tax return for that specific year (see Form 8885 Instructions). Confirm you are using this form to request reimbursement for a month *in* the current calendar year.
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