__________ ___, 2020
Department of the Treasury
Internal Revenue Service
Re: Protective Claim for Refund
Taxpayer’s Name:
Spouse’s Name (if filed jo
intly):
Address:
Taxpayer’s Social Security Number:
Spouse’s Social Security Number (if filed jointly):
Tax Year(s):
Dear Internal Revenue Service:
Please accept this letter as my formal written Protective Claim for Refund of Additional
Medicare Tax and/or Net Investment Income Tax liabilities paid for the tax year(s) set forth
above. These taxes were paid with my/our Form 1040 U.S. Individual Income Tax Return for
the year(s) set forth above. The Additional Medicare Tax liability was set forth on Form 8959,
Part IV, Line 18, and the Net Investment Income Tax liability was set forth on Form 8960, Part
III, Line 17, both of which were timely paid with my/our Form 1040 U.S. Individual Income Tax
Return(s).
A formal written Protective Claim for Refund may be filed when a taxpayer’s right to a refund is
contingent on future events and may not be determinable until after the statute of limitations
expires. The Additional Medicare Tax and Net Investment Income Tax are contingent on the
case pending before the United States Supreme Court, California, et al., Petitioners v. Texas, et
al., No. 19-840. At issue before the United States Supreme Court is whether reducing the
amount specified in 5000A(c) of the Patient Protection and Affordable Care Act (“ACA”) to zero
rendered the minimum coverage provision of the ACA unconstitutional, and if unconstitutional,
whether the minimum coverage provision is severable from the rest of the ACA. If the United
States Supreme Court holds that the minimum coverage provision of the ACA is unconstitutional
and not severable from the rest of the ACA, the Additional Medicare Tax and Net Investment
Income Tax which were assessed pursuant to the ACA would be eliminated and no longer valid.
If the United States Supreme Court holds that the minimum coverage provision of the ACA is
unconstitutional and not severable from the rest of the ACA, and such holding is applicable to
the Additional Medicare Tax and Net Investment Income Tax paid for the tax year(s) set forth
above, taxpayer requests a full refund of such taxes paid and interest, as provided by law, on the
principal amount of the tax overpayment.
If you need additional information, please contact me at the address of record identified above.
Under penalties of perjury, I/we declare that I/we have paid the Additional Medicare Tax and/or
Net Investment Income Tax for the tax years set forth above, and that to the best of my
2016 and 2017
2
knowledge, this Protective Claim for Refund for such taxes, which is contingent on the ruling of
the case pending before the United States Supreme Court, California, et al., Petitioners v. Texas,
et al., No. 19-840, is true, correct and complete.
Dated: _____ ___, 2020
Taxpayer Signature
Dated: _____ ___, 2020
Spouse Signature (if filed jointly)
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