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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 each month an employee received a PTC and whether a safe harbor or other relief applied, as indicated by highlighted months or XF, XG, XH codes.
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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 each month an employee received a PTC and whether a safe harbor or other relief applied, as indicated by highlighted months or XF, XG, XH codes.
Risk Radar
Scan points- 1Failing to correctly highlight months or assign XF, XG, XH codes can cause inaccurate PTC reporting.
- 2Leaving the employer name field blank, preventing identification of the reporting entity.
- 3Omitting the Employer Identification Number, which blocks matching to the employer’s tax records.
- 4Not entering the tax year, causing the listing to be unassociated with a specific filing period.
- 5Failing to provide the employee’s last‑four SSN digits, making the employee unidentifiable.
Plain English
Employers fill out this form to show which months an employee got a premium tax credit and if any safe‑harbor relief was available. The form lists the employee’s name, partial SSN, and a code for each month based on Form 1095‑C.
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 must list each month an employee received a Premium Tax Credit and indicate safe harbor or other relief status.
- Check Form 1095-C instead when reporting the employee's health coverage information required under the employer shared responsibility provisions.
Form selector
Use this form or another form?
Employer must report employee health coverage for ACA compliance
Provides required coverage details for the employer shared responsibility
✓ Verify coverage months and employee data match records
Employee requests proof of coverage for marketplace enrollment
Shows employer‑provided coverage information used to determine eligibility for Premium Tax Credit
✓ Confirm correct employee and plan identifiers
IRS audit of employer shared responsibility compliance
Serves as primary documentation of offers of coverage and employee enrollment status
✓ Ensure all required lines are completed and signatures present
Deadline or filing window
Not stated in the official source.
Checklist
What you need before filling it out
Employer name
Employer's legal name as on IRS records · Form 14765 header
Employer ID number
EIN assigned by IRS · Form 14765 header
Tax year
Calendar year for which PTC is reported · Form 14765 top section
Employee Name (last, first)
Employee's legal name · Form 14765 employee line
SSN (last 4 digits)
Last four digits of employee's Social Security Number · Form 14765 employee line
Indicator Codes (Jan–Dec)
Codes indicating PTC receipt and safe harbor status per month · Form 14765 month columns
Before you submit
- 1Verify the revision date reads Rev. 5-2021 on the form
- 2Enter the employer name in the Employer name field
- 3Enter the Employer ID number in the Employer ID number field
- 4Enter the correct tax year in the Tax year field
- 5Enter each employee’s name in the Employee Name (last, first) field
- 6Enter the employee’s last four SSN digits in the SSN (last 4 digits) field
- 7Highlight months the employee received a PTC where safe harbor applied
- 8Use XF, XG, or XH codes for months where safe harbor is not applicable and attach supporting computation
How to file this form
- 1Complete all required fields on Form 14765 with employer and employee information
- 2Review month indicators and apply XF, XG, or XH codes where safe harbor does not apply
- 3Attach any written request for reconsideration and supporting computations
- 4Submit the completed Form 14765 to the designated IRS address or electronic portal
- 5Retain a copy of the filed Form 14765 and attachments for recordkeeping
Known limitations
- 1Does not apply to employees who did not receive a Premium Tax Credit in any month — Form p.1
- 2Does not apply to months where the employee is not an assessable full‑time employee — Form p.1
- 3Does not apply to safe‑harbor determinations other than those indicated by XF, XG, or XH codes — Form p.1
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 form shows Rev. 5-2021 as the revision date. The source does not reference a latest‑information page or note any changes.
What changed or needs a fresh check
- Edition date — confirm the form shows Rev. 5-2021 as printed on the top
- Fee — Not stated in the official source
- Mailing address — Not stated in the official source
- Signature — Not stated in the official source
Quick Facts
Downloads
After you file
- 1Verify that any month not highlighted corresponds to a month the employee received a PTC with no safe harbor or other relief — Form p.1
- 2Verify that highlighted months indicate a safe harbor or other relief was applicable — Form p.1
- 3Ensure that months showing XF, XG, or XH have a written request for reconsideration and the computation attached — Form p.1
- 4Confirm that Indicator Codes are taken from Form 1095‑C lines 14 and 16 combined — Form p.1
Sources
- SRCForm p.1 — Form 14765 (Rev. 5‑2021) is titled Employee Premium Tax Credit (PTC) Listing.
- SRCForm p.1 — Any month not highlighted indicates the employee received a PTC and no safe harbor or other relief was applicable.
- SRCForm p.1 — The employee is an assessable full‑time employee for that month.
- SRCForm p.1 — Any month that shows XF, XG, or XH denotes a determination that the employee does not qualify for the safe harbor being claimed (2F, 2G, or 2H).
- SRCForm p.1 — If you still think the safe harbor applies, you may provide your computation with your written request for reconsideration.
- SRCForm p.1 — Indicator Codes are from Form 1095‑C, lines 14 and 16 combined.
- SRCNot stated in the official source — verify on the agency site
- SRCNot stated in the official source — verify on the agency site
Common confusion points
Why is a month not highlighted on my Form 14765?
Because any month not highlighted means the employee received a PTC and no safe harbor or other relief was applicable.
→ Check that the month shows no highlight and that the employee indeed received a PTC without safe harbor — Form p.1
What does the XF code mean?
XF indicates a determination that the employee does not qualify for the safe harbor being claimed (2F).
→ Review the safe harbor claim and, if you disagree, attach your computation with a written request for reconsideration — Form p.1
When should I use XG or XH codes?
XG and XH similarly indicate a determination that the employee does not qualify for safe harbors 2G or 2H.
→ Match the code to the specific safe harbor (2G or 2H) and provide supporting documentation — Form p.1
Do I need to list months where the employee did not get a PTC?
Form 14765 only reports months the employee received a PTC; months without PTC are not listed.
→ Leave those months blank or unhighlighted — Form p.1
How are Indicator Codes derived?
Indicator Codes are from Form 1095‑C, lines 14 and 16 combined.
→ Reference the employee’s Form 1095‑C to copy the correct codes — Form p.1
What if I think a safe harbor applies but the form shows XF?
You may provide your computation with a written request for reconsideration.
→ Submit the computation and request as an attachment to the form — Form p.1
Workflow map
Related forms and next steps
Before
Current
After
Often used with
⚠ If something goes wrong
- Submit a written request for reconsideration with your computation for any month showing XF, XG, or XH on Form 14765
Questions about IRS Form 14765
What is IRS Form 14765 used for?
Employers fill out this form to show which months an employee got a premium tax credit and if any safe‑harbor relief was available. The form lists the employee’s name, partial SSN, and a code for each month based on Form 1095‑C.
What information does IRS Form 14765 require?
The form collects the employer’s name and ID number, the tax year, the employee’s name and last‑four SSN digits, and for each month an indicator code (including XF, XG, XH) showing PTC receipt and safe‑harbor status.
How do I complete IRS Form 14765?
Enter the employer name, Employer ID number, and tax year at the top. Provide the employee’s name and last‑four SSN digits. For each of the 12 months, record the appropriate indicator code derived from Form 1095‑C lines 14 and 16. Attach any additional information required for months showing XF, XG, or XH codes.
Why is a month not highlighted on my Form 14765?
Because any month not highlighted means the employee received a PTC and no safe harbor or other relief was applicable. Check that the month shows no highlight and that the employee indeed received a PTC without safe harbor — Form p.1
What does the XF code mean?
XF indicates a determination that the employee does not qualify for the safe harbor being claimed (2F). Review the safe harbor claim and, if you disagree, attach your computation with a written request for reconsideration — Form p.1
When should I use XG or XH codes?
XG and XH similarly indicate a determination that the employee does not qualify for safe harbors 2G or 2H. Match the code to the specific safe harbor (2G or 2H) and provide supporting documentation — Form p.1
Do I need to list months where the employee did not get a PTC?
Form 14765 only reports months the employee received a PTC; months without PTC are not listed. Leave those months blank or unhighlighted — Form p.1
How are Indicator Codes derived?
Indicator Codes are from Form 1095‑C, lines 14 and 16 combined. Reference the employee’s Form 1095‑C to copy the correct codes — Form p.1
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