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Form 14765: Employee Premium Tax Credit (PTC) Listing
IRS Form 14765 is the Employee Premium Tax Credit (PTC) Listing used by employers to report PTC information for their employees. This form lists monthly indicator codes for tax year data.
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IRS Form 14765 - Employee Premium Tax Credit (PTC) Listing
IRS Form 14765 is the Employee Premium Tax Credit (PTC) Listing used by employers to report PTC information for their employees. This form lists monthly indicator codes for tax year data.
Risk Radar
Scan points- 1Ensure every month is accounted for; an unhighlighted month implies a PTC was received and safe harbor applies.
- 2Failing to highlight any month that received a PTC (if safe harbor applies).
- 3Using an incorrect Indicator Code (XF, XG, or XH) when it should be blank/highlighted.
- 4Not including the Employer ID number on IRS Form 14765.
- 5Omitting the Employee's SSN last 4 digits.
Plain English
This form allows an employer to list which months an employee received a Premium Tax Credit (PTC). It shows if the employee qualifies for the credit and notes any specific determination codes for that month. The listing covers all 12 months of the tax year.
Submission Date
- Filing date: 2021-05-04 22:14:54
- 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 an employer needs to list monthly Employee Premium Tax Credit (PTC) data for their employees.
- Do not use this form when reporting PTC information without a specific employee or tax year listed on the form itself.
- Check Form 1095-C instead when reporting the combined indicator codes from lines 14 and 16.
Form selector
Use this form or another form?
Reporting monthly data for an existing employee
The form tracks PTC status month-by-month (Jan through Dec).
✓ Verify all 12 months are accounted for.
When safe harbor relief is claimed but needs justification
If XF, XG, or XH appears, the employer can provide computation on this form.
✓ Ensure written request for reconsideration accompanies the form.
Listing PTC data alongside other employee details
The indicator codes used (e.g., Jan) are combined from lines 14 and 16 of Form 1095-C.
✓ Confirm your monthly code matches the corresponding line on Form 1095-C.
Deadline or filing window
The official source does not state a specific filing deadline for IRS Form 14765. However, the form covers data for a specific Tax year and lists months from January through December.
Checklist
What you need before filling it out
Employer name
Employer's legal name · Form 14765
Employee Name (last, first)
Employee's full name · Form 14765
Indicator Codes
The code entered for each month (e.g., XF, G) · Form 14765
All 12 months
January through December columns · Form 14765
PTC Status (Highlighted Month)
A month highlighted means PTC was received and no safe harbor relief applied. · Form 14765
Safe Harbor Determination
Codes XF, XG, or XH indicate non-qualification for the claimed safe harbor. · Form 14765
Before you submit
- 1Verify the Employer name and Employer ID number on IRS Form 14765 match your records.
- 2Confirm the Tax year listed matches the data being reported for this listing.
- 3Check that every employee has a corresponding SSN (last 4 digits) provided.
- 4Ensure all 12 months have an indicator code entered or highlighted.
- 5If a month is *not* highlighted, confirm it means the employee received PTC and no safe harbor/ESRP relief applied.
- 6If codes XF, XG, or XH are present, verify you can provide your written computation for reconsideration if necessary.
- 7Check that any Additional Information requiring attachment is noted on Form 14765.
How to file this form
- 1Complete the required sections by entering the Employer name and ID number at the top of IRS Form 14765.
- 2List each employee, providing their full Name and SSN (last 4 digits) for easy identification.
- 3For each employee, fill in the indicator codes across all 12 months to show PTC status. Highlight any month where a PTC was received without safe harbor relief.
- 4Attach any supporting documentation referenced in the 'Additional Information' section of IRS Form 14765 before mailing.
Known limitations
- 1A month that is not highlighted indicates an employee received a PTC and no safe harbor or other relief from the ESRP was applicable.
- 2An indicator code of XF, XG, or XH signifies a determination that the employer does not qualify for the claimed safe harbor (2F, 2G, or 2H).
- 3The form applies to assessable full-time employees for any month where an indicator is listed.
- 4If an employee receives a PTC and there is no applicable safe harbor relief, that month must be unhighlighted.
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.
Almost done reviewing the fields?
Fillable formOpen in Editor->The current edition of IRS Form 14765 is dated May 2021 (Rev. 5-2021). The source does not point to a specific 'latest information' page, but it confirms the revision date and catalog number.
What changed or needs a fresh check
- Edition date — confirm May 2021
- Catalog Number — confirm 68863V
- Form Number — confirm 14765
- Signature — Not stated in the official source (though required for filing)
- Tax Year — confirm the specific year being reported
- Indicator Codes — verify all 12 months have a corresponding code.
Quick Facts
Downloads
After you file
- 1Retain a copy of the filed IRS Form 14765 (Rev. 5-2021) for record keeping.
- 2The form is used to report data for a specific Tax year, so retain it until required by the agency.
- 3If an employer believes the safe harbor still applies despite an XF, XG, or XH code, they may provide their computation with a written request for reconsideration.
- 4Ensure all 12 months are accounted for on the form when listing employee data.
Sources
- SRCCatalog Number 68863V is listed for Form 14765 (Rev. 5-2021) on page 1.
- SRCThe form title, Employee Premium Tax Credit (PTC) Listing, appears on page 1.
- SRCThe reporting period covered by the form is specified as 'All 12 months' on page 1.
- SRCA month not highlighted means the employee received a PTC and no safe harbor or other relief from the ESRP was applicable on page 1.
- SRCAn indicator code of XF, XG, or XH indicates a determination that the employer does not qualify for the claimed safe harbor (2F, 2G, or 2H) on page 1.
- SRCThe form must list an employee as assessable full-time for any month where the PTC was received and no safe harbor/relief applied on page 1.
Common confusion points
What does it mean if a month is not highlighted?
This means the employee received a PTC, and no safe harbor or other ESRP relief was applicable that month.
Check the 'All 12 months' column to confirm unhighlighted entries.
Workflow map
Related forms and next steps
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⚠ If something goes wrong
- Not stated in the official source — verify on the agency site
Questions about IRS Form 14765
What is IRS Form 14765 used for?
This form allows an employer to list which months an employee received a Premium Tax Credit (PTC). It shows if the employee qualifies for the credit and notes any specific determination codes for that month. The listing covers all 12 months of the tax year.
Who must file IRS Form 14765?
An employer must file IRS Form 14765 to report the Employee Premium Tax Credit (PTC) information for their employees.
What information does IRS Form 14765 require?
The form collects specific data including the Employer name, Employer ID number, and Tax year. It details each month using Indicator Codes related to Form 1095-C, lines 14 and 16 combined.
Where do I file IRS Form 14765?
The source does not specify a mailing address or electronic submission portal; it references Catalog Number 68863V and www.irs.gov.
How do I complete IRS Form 14765?
The filer must accurately complete all required fields, including the Employer name and Employee SSN (last 4 digits). The form requires listing indicator codes for every month from January through December. Any additional details can be noted in the Additional Information section before signing/submitting.
What happens if IRS Form 14765 is filed incorrectly?
If the information is incorrect, the employer risks misrepresenting whether an employee received a PTC for a given month, which affects tax reporting accuracy.
Source transparency
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