Catalog Number 57559E www.irs.gov
13441-A (Rev. 5-2018)
Part 6: Form Completion
Review this form to make sure you have completed everything needed for your registration. You must sign and date this form to have
your registration for the monthly HCTC program processed. Sign and date in the space provided below.
Under penalties of perjury, I declare that the information furnished on this form with regard to myself and to any family members, and
any attachments to it, is true, correct, and complete. I understand that a knowingly and willfully false statement on this form can result in
my disqualification from the monthly HCTC program. By signing, I authorize the IRS to independently discuss with my health insurer,
third party administrator or former employer, my eligibility status and HCTC payments made on my behalf to these organizations.
Signature Full name (print) Date
Privacy Act and Paperwork Reduction Act Notice
The Privacy Act of 1974 and Paperwork Reduction Act of 1995 require that when we ask you for information we must first tell you our
legal right to ask for the information, why we are asking for it, and how it will be used. We must also tell you what could happen if we do
not receive it and whether your response is voluntary, required to obtain a benefit, or mandatory under the law.
We ask for the information on this form to carry out the Internal Revenue laws of the United States. If you are eligible, section 35 of the
Internal Revenue Code allows a credit for payments you made to buy certain types of health coverage during the tax year. Section
7527 lets you authorize your health coverage provider to receive this credit in advance in the form of monthly payments from the
Internal Revenue Service.
We use the information you submit to determine if you qualify for the monthly credit of the Health Coverage Tax Credit (HCTC). If you
fail to provide the information, or provide inaccurate information, your application may be denied. However, you may still qualify for the
Yearly HCTC when you file your federal income tax return.
The estimated average time to complete this form is 30 minutes. You are required to provide the information requested on a form that is
subject to the Paperwork Reduction Act if the form displays a valid OMB control number. Books or records relating to a form or its
instructions must be retained as long as their contents may be material in the administration of any Internal Revenue laws.
Generally, tax returns and return information (tax information) are confidential, as stated in Code section 6103. However, Code section
6103 allows or requires the Internal Revenue Service to disclose or give the information to others as described in the Code. For
example, we may give the information provided to us to your health plan administrator for the purposes of the HCTC Program. We may
disclose the information you provide to contractors for tax administration purposes. We may also disclose this information to the
Department of Justice, to enforce the tax laws, both civil and criminal; to other federal agencies; to states, the District of Columbia, and
U.S. commonwealths or possessions in order to carry out their tax laws; and to certain foreign governments under tax treaties they
have with the United States.
Part 5: Account Accessibility
If you would like to allow someone else – for example, your spouse, family member, or other trusted advisor – to have access to your
account information, please complete this page. This person, called a Third-Party-Designee, will be able to ask questions about, or
make changes to, your HCTC account or personal information, as appropriate.
Do you want to allow another person to talk with the HCTC Program about your account?
Yes. Complete the rest of this page and choose a PIN.
No. Go to Part 6 to sign and date the HCTC Monthly Registration and Update form.
Name of Third-Party-Designee (First, Middle Initial, Last, Suffix)
Primary telephone number Alternate telephone number
Personal Identification Number (PIN)
IMPORTANT! You must choose a PIN when you make someone a Third-Party-Designee. This PIN protects the security of your
account information similar to the PIN you use for a bank card. When your Third-Party-Designee calls the HCTC Program, they will be
asked to give the PIN to get information about your account. Your Third-Party-Designee can help you choose the PIN so that it is easy
Note: The PIN must be a five-digit number. If your PIN includes letters and/or non-numeric characters, this could cause a delay in
processing your Third-Party-Designee request. Choose a PIN and write it in the space provided.
Personal Identification Number (PIN)
click to sign
click to edit