Fillable Employee Premium Tax Credit (PTC) Listing 2017 Form 14765

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Employee Premium Tax Credit (PTC) Listing 2017 Form 14765

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The Employee Premium Tax Credit (PTC) Listing 2017 Form 14765 form is 1 page long and contains:

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Country of origin: US
File type: PDF

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The Internal Revenue Service (IRS) is a government agency responsible for collecting taxes and administering the federal statutory tax laws of the United States. The IRS provide tax assistance to taxpayers and pursue and resolve fraudulent tax filings.

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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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Employee Premium Tax Credit (PTC) Listing 2017 Form 14765

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Completed 18 May 2019

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