Form 8962
Department of the Treasury
Internal Revenue Service
Premium Tax Credit (PTC)
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Attach to Form 1040, 1040A, or 1040NR.
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Information about Form 8962 and its separate instructions is at www.irs.gov/form8962.
OMB No. 1545-0074
2015
Attachment
Sequence No.
73
Name shown on your return Your social security number
You cannot claim the PTC if your filing status is married filing separately unless you are eligible for an exception (see instructions). If you qualify, check the box.
Part I Annual and Monthly Contribution Amount
1 Tax family size. Enter the number of exemptions from Form 1040 or Form 1040A, line 6d, or Form 1040NR, line 7d 1
2
a
Modified AGI. Enter your modified
AGI (see instructions) . . . . . 2a
b
Enter the total of your dependents'
modified AGI (see instructions) . . .
2b
3 Household income. Add the amounts on lines 2a and 2b . . . . . . . . . . . . . . . . . 3
4
Federal poverty line. Enter the federal poverty line amount from Table 1-1, 1-2, or 1-3 (see instructions). Check the
appropriate box for the federal poverty table used. a
Alaska b Hawaii c Other 48 states and DC
4
5
Household income as a percentage of federal poverty line (see instructions) . . . . . . . . . . . .
5 %
6 Did you enter 401% on line 5? (See instructions if you entered less than 100%.)
No. Continue to line 7.
Yes. You are not eligible to receive PTC. If advance payment of the PTC was made, see the instructions for
how to report your excess advance PTC repayment amount.
7
Applicable Figure. Using your line 5 percentage, locate your “applicable figure” on the table in the instructions . .
7
8
a
Annual contribution amount. Multiply
line 3 by line 7 . . . . . . . 8a
b
Monthly contribution amount. Divide line 8a by
12. Round to whole dollar amount . .
8b
Part II Premium Tax Credit Claim and Reconciliation of Advance Payment of Premium Tax Credit
9
Are you allocating policy amounts with another taxpayer or do you want to use the alternative calculation for year of marriage (see instructions)?
Yes. Skip to Part IV, Shared Policy Allocation, or Part V, Alternative Calculation for Year of Marriage.
No. Continue to line 10.
10
See the instructions to determine if you can use line 11 or must complete lines 12 through 23.
Yes. Continue to line 11. Compute your annual PTC. Then skip lines 12–23
and continue to line 24.
No. Continue to lines 12–23. Compute
your monthly PTC and continue to line 24.
Annual
Calculation
(a) Annual enrollment
premiums (Form(s)
1095-A, line 33A)
(b) Annual applicable
SLCSP premium
(Form(s) 1095-A,
line 33B)
(c) Annual
contribution amount
(line 8a)
(d) Annual maximum
premium assistance
(subtract (c) from (b), if
zero or less, enter -0-)
(e) Annual premium tax
credit allowed
(smaller of (a) or (d))
(f) Annual advance
payment of PTC (Form
(s) 1095-A, line 33C)
11
Annual Totals
Monthly
Calculation
(a) Monthly enrollment
premiums (Form(s)
1095-A, lines 21–32,
column A)
(b) Monthly applicable
SLCSP premium (Form
(s) 1095-A, lines 21–32,
column B)
(c) Monthly
contribution amount
(amount from line 8b
or alternative marriage
monthly contribution)
(d) Monthly maximum
premium assistance
(subtract (c) from (b), if
zero or less, enter -0-)
(e) Monthly premium tax
credit allowed
(smaller of (a) or (d))
(f) Monthly advance
payment of PTC (Form(s)
1095-A, lines 21–32,
column C)
12 January
13 February
14 March
15 April
16 May
17 June
18 July
19 August
20 September
21 October
22 November
23 December
24 Total premium tax credit. Enter the amount from line 11(e) or add lines 12(e) through 23(e) and enter the total here 24
25 Advance payment of PTC. Enter the amount from line 11(f) or add lines 12(f) through 23(f) and enter the total here 25
26
Net premium tax credit. If line 24 is greater than line 25, subtract line 25 from line 24. Enter the difference here and on Form
1040, line 69; Form 1040A, line 45; or Form 1040NR, line 65. If you elected the alternative calculation for marriage, enter zero.
If line 24 equals line 25, enter zero. Stop here. If line 25 is greater than line 24, leave this line blank and continue to line 27 .
26
Part III Repayment of Excess Advance Payment of the Premium Tax Credit
27
Excess advance payment of PTC. If line 25 is greater than line 24, subtract line 24 from line 25. Enter the difference here
27
28 Repayment limitation (see instructions) . . . . . . . . . . . . . . . . . . . . . . 28
29
Excess advance premium tax credit repayment. Enter the smaller of line 27 or line 28 here and on Form 1040, line
46; Form 1040A, line 29; or Form 1040NR, line 44 . . . . . . . . . . . . . . . . . . . 29
For Paperwork Reduction Act Notice, see your tax return instructions.
Cat. No. 37784Z
Form 8962 (2015)
