Fillable Health Coverage Tax Credit (HCTC) Monthly Registration and Update 2018 Form 13441-A

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Health Coverage Tax Credit (HCTC) Monthly Registration and Update 2018 Form 13441-A

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The Health Coverage Tax Credit (HCTC) Monthly Registration and Update 2018 Form 13441-A form is 4 pages long and contains:

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  • 36 check-boxes
  • 52 other fields

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File type: PDF

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Instructions for Form 13441-A
(May 2018)
Health Coverage Tax Credit (HCTC)
Monthly Registration and Update
Department of the Treasury
Internal Revenue Service
Catalog Number 57559E www.irs.gov
Form
13441-A (Rev. 5-2018)
General Instructions
Please read carefully and follow the instructions below to complete Form 13441-A. Write your Social Security Number
at the top of each document you are sending to the HCTC Program. Print or type your responses. To register for the
Monthly HCTC, you must complete the following steps:
1. Collect the documents you will need to submit with your HCTC Monthly Registration and Update form. See the
“Required Supporting Documents” section for a detailed list of the required documents.
2. Fill out the HCTC Monthly Registration and Update form.
3. Make a copy of the completed HCTC Monthly Registration and Update form and all required documents for your
records.
4. Mail the completed HCTC Monthly Registration and Update form and all required documents to:
Internal Revenue Service
Stop 6098 AUSC
Austin, Texas 78741
5. Check here if you are registering as a Qualified Family Member. Note: Qualified Family members of HCTC eligible
individuals may receive the HCTC for up to 24 months following the eligible individual’s Medicare enrollment, death
or divorce. For more information on Qualified Family Member eligibility, see Form 8885 instructions under Qualified
Family Member.
6. Check here if you are updating your current monthly registration. When you are enrolled in the monthly HCTC
Program, you must inform us of all changes that affect your eligibility, your family members and your health
insurance cost. You only need to provide the updated information.
Note: Please note that once you mail the HCTC Monthly Registration and Update form, it can take up to 6 weeks (if
all requirements are met) before you receive registration confirmation. During this time, you must continue to pay
100% of your health insurance bills directly to your health plan and keep records of your payments. You can claim
the yearly tax credit for these and any months that you met all eligibility requirements and made payments directly
to a qualified health plan on your federal income tax return.
Required Supporting Document and Information
The following document is required to be submitted with your HCTC Monthly Registration and Update form. Review the
required document checklist carefully. Caution: An incomplete form or missing documents will delay the processing of
your registration.
A copy of your health insurance bill dated within the last 60 days that includes all of the following:
• Your name
• Monthly premium amount
• Dates of coverage
• Health Plan name and phone number
• Health plan identification numbers
• Address for mailing your payments
If applicable, your bill must show the following:
• Dollar amount for family members who are not qualified for the HCTC
• Separate dollar amount for benefits that the HCTC does not cover (such as separate dental or vision plans)
Usually, your health insurance bill will have all this information on it. If it does not, you will need a letter or another
document from your Health Plan that includes this information.
You should confirm with your Health Plan Provider or Third Party Administrator if applicable that they meet the IRS
payment requirements through the Direct Deposit Program, including filing Form 3881, ACH Vendor/Miscellaneous
Payment Enrollment - HCTC. The IRS requires this in order to make payments on your behalf.
Catalog Number 57559E www.irs.gov
Form
13441-A (Rev. 5-2018)
Your SSN
Form 13441-A
(May 2018)
Department of the Treasury - Internal Revenue Service
Health Coverage Tax Credit (HCTC)
Monthly Registration and Update
OMB Number
1545-1842
Part 1: Your General Information
HCTC Eligible Recipient name (First, Middle Initial, Last, Suffix)
Social Security Number (SSN) Date of birth (mm/dd/yyyy) Primary telephone number Alternate telephone number
Mailing Address (Street Number, City, State, ZIP)
Part 2: Confirm Your Eligibility
Check the box that applies to you to certify that the statement is true:
The HCTC Eligible Recipient is a PBGC payee and 55 years old or older.
You will check the box below if you are registering as the HCTC Eligible Recipient or Qualifying Family Member.
Note: Qualified Family members of HCTC eligible individuals may receive the HCTC for up to 24 months following the eligible
individual’s Medicare enrollment, death or divorce. For more information on Qualified Family Member eligibility, see Form 8885
instructions under Qualified Family Member.
I certify that all of the following statements are true for me and my qualified family members.
• I/we are not enrolled in an Affordable Care Act Marketplace insurance.
• I/we are covered by a qualified health plan for which I pay more than 50% of the premiums.
• I/we are not enrolled in Medicare Part A, B, C, or D.
• I/we are not enrolled in Medicaid or the Children’s Health Insurance Program (CHIP).
• I/we are not enrolled in the Federal Employees Health Benefits Program (FEHBP).
• I/we are not enrolled in the U.S. military health system (TRICARE).
• I/we are not imprisoned under federal, state, or local authority.
• I/we are not claimed as a dependent on someone else’s federal income tax return.
Part 3: Family Member Information
If you have more than five (5) qualified family members, make a copy of this page and then complete this section for any additional
family members.
Please list the total number of family members (other than yourself) you are registering for the Monthly HCTC.
Check the box to certify that the following applies to each family member listed below:
• My family member is my spouse or claimed as a dependent on my federal income tax return and
• My family member meets all general requirements for the HCTC listed in Part 2 (with the exception of the last bullet).
The HCTC Eligible Recipient is an eligible Trade Adjustment Assistance (TAA), Alternative TAA (ATAA), or Reemployment TAA
(RTAA) recipient.
2
Family member’s name (First, Middle Initial, Last, Suffix) Social security number (SSN) Date of birth (mm/dd/yyyy)
Relationship to you
Spouse Child Other
Is this person on your health plan?
Yes
No. This person has a separate qualified plan. Make a copy of the next page
and use Part 4 to provide their health insurance information.
1
Family member’s name (First, Middle Initial, Last, Suffix) Social security number (SSN) Date of birth (mm/dd/yyyy)
Relationship to you
Spouse Child Other
Is this person on your health plan?
Yes
No. This person has a separate qualified plan. Make a copy of the next page
and use Part 4 to provide their health insurance information.
Page 3
Catalog Number 57559E www.irs.gov
Form
13441-A (Rev. 5-2018)
Your SSN
Part 4: Health Plan Information
Fill out the information below. If your family members are on a separate health plan, make a copy of Part 4 before filling it out to provide
their qualified health insurance information.
Note: If you have coverage through your spouse’s employer that is not a COBRA plan, stop here. You cannot receive the Monthly
HCTC for this type of coverage. You can, however, claim the Yearly HCTC by filing Form 8885 with your federal income tax
return.
Complete this
section for all
coverage types:
Health Plan Provider name Effective date of coverage Health plan ID number
HCTC vendor name (name of company to be payed on your behalf)
HCTC vendor number (contact your Health Plan Provider or Third Party Administrator)
Provide at least one of the following ID Numbers.
Member ID Group ID Policy or plan ID
Policy holder’s name (First, Middle Initial, Last, Suffix) Policy holder’s SSN
1. Total Monthly Medical Premium
2. Total number of people (you and any family members) on this policy
3. Number of family members on this policy who are not qualified for the HCTC
4. Monthly premium amount for family members who are not qualified for the HCTC
(this amount will be removed from your total monthly medical premium and you will need to
pay directly to your HPA/TPA).
5. Total HCTC Total Monthly Medical Premium Line (1) minus line (4) and
multiplied by 27.5% (.275)
6. Other health benefits amount (vision, dental, non-medical benefits). This amount
will be added to your monthly HCTC payment.
7. Monthly HCTC payment Line 5 plus Line 6
Former employer Former employer’s HR telephone number
Complete this
section only if you
have COBRA
coverage:
Start Date for COBRA Coverage (mm/dd/yyyy) End Date for COBRA Coverage (mm/dd/yyyy)
Check here if this is a Lifetime Benefit.
Check here only if the Health Plan Information in Part 4 is for COBRA Coverage.
3
Family member’s name (First, Middle Initial, Last, Suffix) Social security number (SSN) Date of birth (mm/dd/yyyy)
Relationship to you
Spouse Child Other
Is this person on your health plan?
Yes
No. This person has a separate qualified plan. Make a copy of the next page
and use Part 4 to provide their health insurance information.
4
Family member’s name (First, Middle Initial, Last, Suffix) Social security number (SSN) Date of birth (mm/dd/yyyy)
Relationship to you
Spouse Child Other
Is this person on your health plan?
Yes
No. This person has a separate qualified plan. Make a copy of the next page
and use Part 4 to provide their health insurance information.
5
Family member’s name (First, Middle Initial, Last, Suffix) Social security number (SSN) Date of birth (mm/dd/yyyy)
Relationship to you
Spouse Child Other
Is this person on your health plan?
Yes
No. This person has a separate qualified plan. Make a copy of the next page
and use Part 4 to provide their health insurance information.
$0.00
$0.00
dd mmm yyyy
dd mmm yyyy
dd mmm yyyy
dd mmm yyyy
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Page 4
Catalog Number 57559E www.irs.gov
Form
13441-A (Rev. 5-2018)
Your SSN
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.
Signature
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.
Third-Party-Designee
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
to remember.
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)
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Health Coverage Tax Credit (HCTC) Monthly Registration and Update 2018 Form 13441-A

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Completed 14 May 2019

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