Catalog Number 68863V www.irs.gov
Form
14765 (4-2017)
Form 14765
(April 2017)
Department of the Treasury - Internal Revenue Service
Employee Premium Tax Credit (PTC) Listing
Employer name Employer ID number Tax year
Employee Name
(last, first)
SSN
(last 4
digits)
All 12 months
Indicator
Codes
(Form 1095-C,
lines 14 and 16
combined)
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Additional
Information
Attached
Any month not highlighted is a month that the employee received a PTC and no safe harbor or other relief from the ESRP was applicable. The employee is an assessable full-time
employee for that month.
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