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Form 8885 Department of the Treasury Internal Revenue Service Health Coverage Tax Credit a Attach to Form 1040, Form 1040NR, Form 1040-SS, or Form 1040-PR. a . OMB No. 1545-0074 20 13 Attachment Sequence No. 134 Name of recipient (if both spouses are recipients, complete a separate form for each spouse) Recipient•s social security number Before you begin: See Definitions and Special Rules in the instructions. F ! CAUTION Do not complete this form if you can be claimed as a dependent on someone else’s 2013 tax return. Part I Complete This Part To See if You Are Eligible To Take This Credit 1 Check the boxes below for each month in 2013 that all of the following statements were true on the first day of that month. • You were an eligible trade adjustment assistance (TAA) recipient, alternative TAA (ATAA) recipient, reemployment TAA (RTAA) recipient, or Pension Benefit Guaranty Corporation (PBGC) pension payee; or you were a qualified family member of an individual who fell under one of the categories listed above when he or she passed away or with whom you finalized a divorce. • You and/or your family member(s) were covered by a qualified health insurance plan for which you paid the entire premiums, or your portion of the premiums, directly to your health plan or to “U.S. Treasury–HCTC.” • You were not enrolled in Medicare Part A, B, or C, or you were enrolled in Medicare but your family member(s) qualified for the HCTC. • You were not enrolled in Medicaid or the Children’s Health Insurance Program (CHIP). • You were not enrolled in the Federal Employees Health Benefits Program (FEHBP) or eligible to receive benefits under the U.S. military health system (TRICARE). • You were not imprisoned under federal, state, or local authority. • Your employer did not pay 50% or more of the cost of coverage. • You did not receive a 65% COBRA premium reduction from your former employer or COBRA administrator. January February March April May June July August September October November December Part II Health Coverage Tax Credit 2 Enter the total amount paid directly to your health plan for qualified health insurance coverage for the months checked on line 1 (see instructions). Do not include on line 2 any qualified health insurance premiums paid to “U.S. Treasury–HCTC” or any insurance premiums on coverage that was actually paid for with a National Emergency Grant. Also, do not include any advance (monthly) payments or reimbursement credits you received as shown on Form 1099-H, box 1 . . 2 F ! CAUTION You must attach the required documents listed in the instructions for any amounts included on line 2. If you do not attach the required documents, your credit will be disallowed. 3 Enter the total amount of any Archer MSA or health savings accounts distributions used to pay for qualified health insurance coverage for the months checked on line 1 . . . ........ 3 4 Subtract line 3 from line 2. If zero or less, stop; you cannot take the credit ........ 4 5 Health Coverage Tax Credit. If you received an advance (monthly) payment in any month not checked on line 1, see the instructions for line 5 for more details. Otherwise, multiply the amount on line 4 by 72.5% (.725). Enter the result here and on Form 1040, line 71 (check box c ); Form 1040NR, line 67 (check box c ); Form 1040-SS, line 10; or Form 1040-PR, line 10 ...... 5 For Paperwork Reduction Act Notice, see your tax return instructions. Cat. No. 34641D Form 8885 (2013) Information about Form 8885 and its instructions is at www.irs.gov/form8885 ----------------Page (0) Break----------------