8885 forma Instrukcijos
8885 formos nurodymai: sveikatos draudimo mokesčio kreditas
2021 metai
Susijusios formos
- Forma - Sveikatos draudimo mokesčio kreditas
Department of the Treasury
Internal Revenue Service
2021
Instructions for Form 8885
Health Coverage Tax Credit
Section references are to the Internal Revenue
Code unless otherwise noted.
Any amounts you included on Form
for those coverage months. Your election
applies to your April through October
coverage months.
•
8885, line 4, or on Form 14095, The
Health Coverage Tax Credit (HCTC)
Reimbursement Request Form;
What’s New
Even if you can’t claim the HCTC
Any qualified health insurance
•
Expiration of the Health Coverage Tax
Credit (HCTC). The HCTC expires at the
end of 2021. The HCTC can't be claimed
for coverage months beginning in 2022.
The advance monthly payment program
will continue through December 2021 but
will not accept HCTC payments in 2022.
on your income tax return, you
!
coverage premiums you paid to “US
Treasury-HCTC” for eligible coverage
months for which you received the benefit
of the advance monthly payment program;
or
CAUTION
must still file Form 8885 to elect
the HCTC for any months you participated
in the advance monthly payment program.
Failing to make a timely election will
require you to report advance monthly
HCTC payment amounts as an additional
tax owed on your tax return.
Any advance monthly payments your
•
health plan administrator received from
the IRS, as shown on Form 1099-H,
Health Coverage Tax Credit (HCTC)
Advance Payments.
COBRA premium reductions. The
American Rescue Plan Act of 2021
provided temporary 100% premium
subsidies for eligible former employees
enrolled in COBRA coverage. If you
received a 100% COBRA premium
reduction from your former employer or
COBRA administrator, don’t check any
boxes on line 1 for the coverage months
for which you received such reduction.
You aren’t eligible to claim the HCTC for
those months and may need to repay on
line 5 any advance payments of the HCTC
made for your benefit for those months.
Definitions and Special
Rules
Who Can Take This Credit
TAA Recipient
You can elect to take the HCTC only if (a)
you were an eligible TAA, ATAA, or RTAA
recipient or PBGC payee in 2021; or you
were the qualifying family member of an
eligible TAA, ATAA, or RTAA recipient or
PBGC payee who passed away or
You were an eligible TAA recipient as of
the first day of the month if, for any day in
that month or the prior month, you:
Received a trade readjustment
•
allowance, or
finalized a divorce with you (see
Would have been entitled to receive
•
such an allowance except that you hadn’t
exhausted all rights to any unemployment
insurance (except additional
Members After Certain Life Events, later);
(b) you can’t be claimed as a dependent
on someone else’s 2021 tax return; and
(c) you met all of the other conditions
listed on line 1. If you can’t be claimed as
a dependent on someone else’s 2021 tax
return, review Form 8885, Part I, to see if
you are eligible to take this credit.
Future Developments
compensation that is funded by a state
and isn’t reimbursed from any federal
funds) to which you were entitled (or
would be entitled if you applied).
For the latest information about
developments related to Form 8885 and
its instructions, such as legislation
enacted after they were published, go to
Example. You received a trade
readjustment allowance for January 2021.
You were an eligible TAA recipient as of
the first day of January and February.
Relatively few people are eligible
Election to take the HCTC. You must
elect the HCTC to receive the benefit of
the HCTC. Make your election by
for the HCTC. See Who Can Take
!
CAUTION
This Credit, later, to determine
ATAA Recipient
whether you can claim the credit.
checking the box on line 1 for the first
eligible coverage month you are electing
to take the HCTC and all boxes on line 1
for each eligible coverage month after the
election month. Once you elect to take the
HCTC for a month in 2021, the election to
take the HCTC applies to all subsequent
eligible coverage months in 2021. The
election doesn’t apply to any month for
which you aren’t eligible to take the HCTC.
You were an eligible ATAA recipient as of
the first day of the month if, for that month
or the prior month, you received benefits
under an alternative trade adjustment
assistance program for older workers
established by the Department of Labor.
General Instructions
Purpose of Form
Use Form 8885 to elect and figure the
amount, if any, of your HCTC.
Example. You received benefits under
an alternative trade adjustment assistance
program for older workers for October
2021. The program was established by
the Department of Labor. You were an
eligible ATAA recipient as of the first day
of October and November.
Self-Employed Health Insurance De-
duction Worksheet. If you are
For 2021, the election must be made
no later than the due date (including
extensions) of your tax return.
completing the Self-Employed Health
Insurance Deduction Worksheet in your
tax return instructions and you were an
eligible trade adjustment assistance (TAA)
recipient, alternative TAA (ATAA)
recipient, reemployment TAA (RTAA)
recipient, or Pension Benefit Guaranty
Corporation (PBGC) payee, you must
complete Form 8885 before completing
that worksheet. When figuring the amount
to enter on line 1 of the worksheet, do not
include:
Example. You were an eligible RTAA
recipient between February 2021 and
October 2021 and you otherwise met the
HCTC requirements during that period.
You wish to take the HCTC starting in April
2021. You would check the box on line 1
for April to elect the HCTC for your April
coverage. You must then check every box
on line 1 through, and including, October
because you’re eligible to take the HCTC
RTAA Recipient
You were an eligible RTAA recipient as of
the first day of the month if, for that month
or the prior month, you received benefits
under a reemployment trade adjustment
assistance program for older workers
established by the Department of Labor.
Dec 01, 2021
Cat. No. 68158V
Example. You received benefits under
a reemployment trade adjustment
described in section 9832(c). For
example, if you purchase dental or vision
benefits separately, these benefits aren’t
qualified health insurance coverage. But, if
you purchase dental or vision benefits as
part of a comprehensive package and
these benefits don’t represent
Qualified Health Insurance
Coverage
assistance program for older workers for
January 2021. The program was
Qualified health insurance coverage for
the HCTC is any of the following.
established by the Department of Labor.
You were an eligible RTAA recipient as of
the first day of January and February.
1. Coverage under a group health
plan available through the employment of
your spouse, but see the instructions for
line 1, later, for information on when
enrollment in, or an offer of,
substantially all of its coverage, the
comprehensive package of benefits,
including the dental and vision benefits,
may be qualified health insurance
coverage and the premiums paid may be
eligible for the HCTC.
PBGC Payee
You were an eligible PBGC payee as of
the first day of the month if both of the
following apply.
employer-sponsored coverage makes you
an individual ineligible for the HCTC.
1. You were age 55 to 65 and not
enrolled in Medicare as of the first day of
the month.
2. You received a benefit for that
month that was paid by the PBGC under
title IV of the Employee Retirement
Income Security Act of 1974 (ERISA).
2. Coverage under a non-group
(individual) health insurance plan other
than a qualified health plan offered
through a Marketplace. Individual health
insurance doesn’t include any insurance
connected with a group health plan or
federal- or state-based health insurance
coverage.
3. Coverage under a Consolidated
Omnibus Budget Reconciliation Act
(COBRA) continuation provision (as
defined in section 9832(d)(1)).
For more information about
whether your coverage is qualified
health insurance coverage, go to
TIP
Qualifying Family Member
A qualifying family member is:
If you received a lump-sum payment
from the PBGC after August 5, 2002, you
meet item (2) above for any month that
you would have received a PBGC benefit
if you hadn’t received the lump-sum
payment.
Your spouse (a spouse doesn’t include
•
someone who is legally separated from his
or her spouse under a decree of divorce or
of separate maintenance (but see Married
Persons Filing Separate Returns, later)),
or
4. State-based coverage. State-based
coverage includes the following.
Continued Qualification for
Family Members After Certain
Life Events
Anyone whom you can claim as a
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a. Continuation coverage provided by
the state under a state law that requires
such coverage.
b. A qualified state high-risk pool (as
defined in section 2744(c)(2) of the Public
Health Service Act).
dependent (but see the exception for
Parents, later).
Qualifying family members (spouses and
dependents) (see Qualifying Family
Member, later) can be considered
For any month that you are eligible to
take the HCTC, you can include premiums
paid for a qualifying family member for that
eligible coverage month if all of the
recipients and file Form 8885 under their
name and social security number after
certain life events. You are considered a
recipient and are eligible to newly receive,
or continue to receive, the HCTC in the
event that a related TAA, ATAA, or RTAA
recipient or PBGC payee dies or finalizes
a divorce with you and you were a
c. A health insurance program offered
for state employees.
following statements were true as of the
first day of that eligible coverage month.
d. A state-based health insurance
program that is comparable to the health
insurance program offered for state
employees.
e. An arrangement entered into by a
state and (i) a group health plan (including
such a plan that is a multiemployer plan as
defined in section 3(37) of ERISA), (ii) an
issuer of health insurance coverage, (iii)
an administrator, or (iv) an employer.
f. A state arrangement with a private
sector health care coverage purchasing
pool.
g. A state-operated health plan that
doesn’t receive any federal financial
participation.
The qualifying family member was
•
covered by qualified health insurance
coverage for which you paid some or all of
the premiums. You and your qualifying
family member don’t have to be covered
by the same coverage.
qualifying family member immediately
before such event. The TAA, ATAA, or
RTAA recipient or PBGC payee doesn’t
need to elect the HCTC prior to the event.
People who were qualifying family
The qualifying family member wasn’t
•
enrolled in Medicare Part A, B, or C.
The qualifying family member wasn’t
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enrolled in Medicaid or the Children’s
Health Insurance Program (CHIP).
members can receive the tax credit for
eligible coverage months up to 24 months
from the death or divorce, or until the first
coverage month that begins on or after
January 1, 2022, whichever comes first.
Eligibility to receive the HCTC may begin
in either the month of the death or divorce
or the month following the death or
divorce.
Example. Your spouse was a PBGC
payee and died on August 20, 2020. You
are eligible to receive the HCTC as a
recipient for coverage for August 2020
through December 2021, subject to the
other general HCTC requirements. If you
didn't have separate coverage for August,
you are eligible to receive the HCTC as a
recipient for coverage for September 2020
through December 2021, subject to the
other general HCTC requirements.
The qualifying family member wasn’t
•
enrolled in the Federal Employees Health
Benefits Program (FEHBP) or eligible to
receive benefits under the U.S. military
health system (TRICARE).
The qualifying family member wasn’t
•
5. Coverage under a health plan
covered by, or eligible for coverage under,
any employer-sponsored health insurance
coverage as described in the instructions
funded by a voluntary employees’
beneficiary association (VEBA) that was
established through a bankruptcy court.
Exception. Qualified health insurance
coverage doesn’t include any of the
following.
Note. If you are an eligible TAA, ATAA, or
RTAA recipient or PBGC payee who
enrolled in Medicare, you may be able to
take the HCTC for coverage of qualifying
family members. You can receive the
HCTC for the health plan premiums of
your qualifying family member(s) for
eligible coverage months up to 24 months
from the month you enrolled in Medicare,
or until the first coverage month that
begins on or after January 1, 2022,
Any state-based coverage listed in
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items 4a through 4g above unless it also
meets the requirements of section 35(e)
(2).
A flexible spending or similar
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arrangement.
Any insurance if substantially all of its
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coverage is of excepted benefits
Instructions for Form 8885 (2021)
-2-
whichever comes first. In order to receive
resided with each parent for an equal
different coverage. For example, if you
elect the HCTC for self-only COBRA
coverage in a month, you can take the
PTC for the Marketplace coverage of your
family members for that same month if you
and your eligible family members are
otherwise eligible to take the PTC and the
HCTC, as applicable.
the HCTC, your qualifying family members number of nights in 2021, the custodial
must meet all of the requirements
described earlier.
parent is the parent with the higher
adjusted gross income for 2021.
The child’s other parent can claim the
•
Married Persons Filing
Separate Returns
child as a dependent under the rules for
children of divorced or separated parents.
See the Instructions for Forms 1040 and
1040-SR, or Pub. 501, Dependents,
Standard Deduction, and Filing
Your spouse isn’t treated as a qualifying
family member if you and your spouse file
separate returns and either (1) or (2)
below applies.
You may also be able to claim the
HCTC and the PTC for different coverage
of the same individuals in different months
of the year but need to apply the following
special instructions for completing Form
8962. If you elected to take the HCTC or
received the benefit of advance payments
of the HCTC for at least 1 month of the
year and the individual(s) covered under
the qualified health insurance coverage for
the HCTC were also enrolled in a qualified
health plan offered through a Marketplace
for at least 1 other month of the year,
complete Form 8962 as provided in the
Form 8962 instructions, but:
Information, for details.
1. Your spouse was also an eligible
TAA, ATAA, or RTAA recipient or PBGC
payee in 2021.
Conversely, if you can claim your child
as a dependent under the special rule for
a child of divorced or separated parents
but you aren’t the child’s custodial parent,
the child isn’t your qualifying family
2. All of the following apply.
a. You lived apart from your spouse
member for purposes of the HCTC.
during the last 6 months of 2021.
The child must also meet all the
b. A qualifying family member (other
than your spouse) lived in your home for
more than half of 2021.
other conditions of a qualifying
!
CAUTION
family member, defined earlier, in
order for you to claim the HCTC for the
qualified health insurance coverage of the
child.
c. You provided over half of the cost
of keeping up your home.
Figure your PTC for only those months
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Children of Divorced or
Separated Parents
not checked on Form 8885, line 1;
Complete Form 8962, column (f) of
Participants in a Health
Insurance Marketplace
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lines 12 through 23, for all months for
which advance payments of the premium
tax credit (APTC) were made, even those
months checked on Form 8885, line 1;
and
Even if you can’t claim your child as a
dependent, he or she is treated as your
qualifying family member for the HCTC if
both of the following apply.
A qualified health plan offered through a
Marketplace isn’t qualified health
insurance coverage for the HCTC in 2021.
And you can’t take the premium tax credit
(PTC) for any months checked on line 1.
However, subject to the general eligibility
and election rules for the HCTC and the
PTC, you may be able to claim the PTC
and the HCTC in the same month for
You were the child’s custodial parent.
•
If you complete Form 8962, line 27
•
Generally, the custodial parent is the
parent with whom the child resided for the
greater number of nights in 2021. If the
counting nights rule applies, and the child
(Excess advance payment of PTC),
determine Form 8962, line 28 (Repayment
limitation), as follows.
Instructions for Form 8885 (2021)
-3-
IF . . .
THEN . . .
the amount on Form 8962, line 5, is 400 or more,
the amount on Form 8962, line 24, is zero or blank,
leave Form 8962, line 28, blank and enter the amount from line 27 on line 29.
leave Form 8962, line 28, blank and enter the amount from line 27 on line 29.
you didn’t receive the benefit of advance monthly payments of the HCTC, leave Form 8962, line 28, blank and enter the amount from line 27 on line 29.
the amount on Form 8962, line 24, is greater than zero,
after you complete Form 8962, line 27, complete Form 8885.
and
for Form 8885, line 5, add the amount from Form 8885, line 5, if any, to the applicable
repayment limitation provided in the instructions for Form 8962, line 28. Enter the result
on Form 8962, line 28, and complete Form 8962, line 29.
you received the benefit of advance monthly payments of the HCTC for
at least 1 month of the year for individual(s) who were enrolled in a
qualified health plan offered through a Marketplace for at least 1 other
month of the year,
Form 8885, line 5, complete only lines 1 and 2 of the worksheet and do one of the
following.
(1) If line 1 of the worksheet is greater than or equal to line 2 of the worksheet:
(a) Complete line 3 of the worksheet and enter the amount on Form 8885, line 5,
and Schedule 3 (Form 1040), 1040-SS, or 1040-PR, as instructed;
(b) On Form 8962, line 28, enter the sum of the amount on Form 8885, line 5,
and the applicable repayment limitation provided in the instructions for Form
8962, line 28; and
(c) Complete Form 8962, line 29.
(2) If line 1 of the worksheet is less than line 2 of the worksheet:
(a) Complete Form 8962, lines 28 and 29, using the applicable repayment
limitation provided in the Instructions for Form 8962 without any
adjustments; and
(b) Using this information, complete lines 4 through 7 of the worksheet as
instructed.
a. You were eligible for qualified
health insurance coverage (including any
Line 2
Specific Instructions
Line 1
If your qualified health insurance
employer-sponsored health insurance
plan of your spouse) (other than the
coverage listed under item 3, 4a, or 4e in
the definition of Qualified Health Insurance
Coverage, earlier) where the employer
would have paid 50% or more of the cost
of the coverage.
coverage covers anyone other
than you and your qualifying
!
CAUTION
You must elect the HCTC to receive the
benefit of the HCTC. Check the box for the
first eligible coverage month you are
electing to take the HCTC. All of the
statements listed on the form, and as
further explained in these instructions,
must be true as of the first day of that
month. You must also check the box for
each month after the election month for
which all of the statements listed on the
form are true as of the first day of that
month, even if you aren’t claiming the
HCTC for those months.
family members, see Pub. 502, Medical
and Dental Expenses, before completing
line 2 to determine which amounts are
considered to be paid for coverage for you
and your qualifying family members.
b. You were covered under any
qualified health insurance coverage
(including any employer-sponsored health
insurance plan of your spouse) (other than
the coverage listed under item 3, 4a, or 4e
in the definition of Qualified Health
Insurance Coverage, earlier) and the
employer paid any part of the cost of the
coverage.
Enter the total amount of insurance
premiums paid by you for coverage for
you and all qualifying family members
Coverage, earlier, for all eligible coverage
months checked on line 1. But don’t
include any insurance premiums paid by
you to “US Treasury-HCTC.” Also don’t
include any advance monthly payments
your health plan administrator received
from the IRS, as shown on Form 1099-H,
box 1, or any insurance premiums you
paid for which you received a
Employer-sponsored health insurance
coverage. Don’t check the box for any
month that, as of the first day of the month,
either (1) or (2) applies.
1. You were covered under any
employer-sponsored health insurance
plan (including any employer-sponsored
health insurance plan of your spouse)
(except insurance substantially all of the
coverage of which is of excepted benefits
described in section 9832(c)) and the
employer paid 50% or more of the cost of
the coverage.
Any amounts contributed to the
cost of coverage by you or your
!
CAUTION
spouse on a pre-tax basis are
considered to have been paid by the
employer.
reimbursement of the HCTC during the
year by filing Form 14095.
Example. You had health insurance
coverage under an employer-sponsored
health insurance plan as of October 1. The
employer paid 40% of the cost of the
coverage. You paid 60% of the cost of the
coverage through pre-tax contributions.
You can’t take the HCTC for the month of
October because the employer is
Example 1. You checked January on
line 1. You paid $225 ($200 for basic
coverage and $25 for dental benefits
which are purchased separately) directly
to your health plan for your January
coverage. The $25 you paid for dental
benefits is ineligible for the HCTC. You
would include the $200 you paid for your
basic insurance on line 2.
2. You were an eligible ATAA or
RTAA recipient and either of the following
applies.
considered to have paid 100% of the cost
of the coverage.
Instructions for Form 8885 (2021)
-4-
Excess Advance HCTC Repayment Worksheet—Line 5
1. Multiply the amount from Form 8885, line 4, by 72.5% (0.725)
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1.
2.
2. Enter the total advance monthly payments of the HCTC made on your behalf for coverage for any month not checked on Form 8885, line 1 (see
Form 1099-H) and reimbursements of the HCTC you received by filing Form 14095 for any month not checked on Form 8885, line 1. If line 2 is
greater than line 1, skip line 3 and go to line 4
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3. Subtract line 2 from line 1. Enter the result here and on:
Form 8885, line 5; and
•
•
Schedule 3 (Form 1040), line 13c; Form 1040-SS, line 10; or Form 1040-PR, line 10.
Don’t complete the rest of this worksheet
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4. Subtract line 1 from line 2. Enter the result here
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5. Consider all the individual(s) covered under the health insurance coverage for which you received the benefit of the advance monthly payments
of the HCTC during the year. Were any of those individual(s) also enrolled in a qualified health plan offered through a Marketplace for at least 1
other month of the year?
Yes. Complete Form 8962 using the special instructions under Participants in a Health Insurance Marketplace, earlier. Go to line 6.
•
No. Skip line 6. Enter the amount from line 4 on line 7.
•
6. Is the amount on Form 8962, line 5, less than 400 AND the amount on Form 8962, line 24, greater than zero?
Yes.
•
IF . . .
THEN enter on line 6 . . .
Form 8962, line 28, is blank,
the sum of Form 8962, line 26, and the
applicable repayment limitation provided in the
instructions for Form 8962, line 28.
Form 8962, line 28, isn’t blank,
Form 8962, line 28, reduced by Form 8962,
line 29.
Note. If you are married filing jointly and both you and your spouse must file Forms 8885, one spouse should
figure their repayment limitation on line 6 of this worksheet. If line 6 is greater than line 7, enter the difference
on line 6 of the second spouse’s worksheet. Otherwise, enter zero on lines 6 and 7 of the second spouse’s
worksheet.
No. Leave line 6 blank. Enter the amount from line 4 on line 7.
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•
6.
7. If you entered an amount on line 6, enter the smaller of line 4 or line 6 here. Also enter the items below where indicated.
IF you’re filing . . .
THEN include the amount on
line 7 in the total entered on . . .
AND enter “HCTC” and the amount on line 7 . . .
in the space next to box 3 on line 16; then check box 3.
on the dotted line next to line 6.
Form 1040, 1040-SR, or
1040-NR,
line 16
Form 1040-SS or 1040-PR,
line 6
Then, on Form 8885, line 5, enter the line 7 amount as a negative number by enclosing it in parentheses.
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7.
Example 2. You checked December
on line 1. You participated in the advance
monthly payment program and paid only
$88 (27.5%) of your $320 December
premium to “US Treasury-HCTC.” You
received a Form 1099-H showing an
advance payment of $232 (72.5% of the
$320 premium) for your December
received the benefit of an advance
Line 5
monthly payment for any month not
If the resulting amount from line 5 is
negative, zero, or blank, you can’t claim
the HCTC on your income tax return.
However, you must still file Form 8885 to
elect the HCTC for any months you
participated in the advance monthly
payment program.
checked on line 1 (see Form 1099-H) or
received a reimbursement of the HCTC
during the year by filing Form 14095 for
any month not checked on line 1. You
must reduce the amount on line 5 by the
total of these payments. Use the Excess
figure the amount of the excess advance
monthly payment that you must repay.
coverage. You wouldn’t include any part of
the December coverage premium on line 2
because you already received the benefit
of the advance monthly payment program
for December. You must still file Form
8885 to elect the HCTC for December.
You received an excess advance
monthly payment of the HCTC if you
Instructions for Form 8885 (2021)
-5-
count towards the HCTC, such as dental
or vision coverage or coverage for family
cost of the coverage (TAA recipients and
PBGC payees) or made no contributions
Required Documents
If you claim any HCTC on line 5, you must
provide verifiable proof for each month
you are claiming the credit on line 2 that
your health insurance coverage is
members who aren’t eligible for the HCTC, to the cost of coverage (ATAA and RTAA
your documentation must also specify
those ineligible amounts.
3. Proof of payment for each month
you are claiming the credit on line 2, such
as:**
recipients).
E-filed return. If you e-file, you can
qualified health insurance coverage for the
HCTC and that you paid premiums for the
qualified health insurance coverage by
attaching the documents listed below to
your Form 8885. No documents are
attach a copy of any required documents
to an electronically filed return as a PDF if
your tax software supports it, or you must
a. Canceled checks (copy of front and attach those documents to Form 8453,
back),
U.S. Individual Income Tax Transmittal for
an IRS e-file Return, and mail them to the
IRS according to the instructions for that
form.
required if you file Form 8885 only to elect
the HCTC for months you participated in
the advance monthly payment program.
b. Bank statements,
c. Credit card statements, or
d. Money orders.
Example 1. You checked June and
July on line 1. Your insurance coverage for
each month costs $750 ($500 for you and
$250 for your qualifying family members).
You paid $750 directly to your health plan
for your June coverage. You then paid
$206.25 (27.5% of the $750 premium) for
your July coverage as part of the advance
monthly payment program. Your health
plan administrator received an advance
payment of $543.75 (72.5% of the $750
premium) from the IRS for your July
All health plans. For all health plans,
you must include all of the following
documents.
1. An official letter reflecting that you
were an eligible individual for the months
claimed on line 2 in 2021.
**Your proof of payment must indicate
the amount paid and to whom it was paid.
If you don’t have one of these types of
proof of payment, contact your health plan
for a record of your payment(s).
For trade-certified individuals
•
COBRA coverage. You must include
earlier, and one of the following
documents.
1. A copy of your completed and
signed COBRA Election Letter. It may also
be called a COBRA Enrollment Form,
Application Form, Enrollment Application
for Continuing Coverage, or Election
Agreement.
demonstrating TAA, ATAA, or RTAA
eligibility—A copy of the official letter from
the Department of Labor, your state
workforce agency, or employment office
stating you are eligible for trade
adjustment benefits.
coverage. You received a Form 1099-H
showing an advance payment of $543.75
for your July coverage. You would include
the $750 you paid for your June coverage
on line 2. You wouldn’t include any part of
the July coverage premium on line 2
because you already received the benefit
of the advance monthly payment program
for July. You must attach copies of your
health insurance bills and proof of
For PBGC eligibility—A copy of the
•
official letter or a copy of your 2021 Form
1099-R, Distributions From Pensions,
Annuities, Retirement or Profit-Sharing
Plans, IRAs, Insurance Contracts, etc.,
from the PBGC showing you received a
benefit paid by the PBGC.
2. A letter from your former employer
or COBRA administrator saying you have
COBRA coverage. The letter must have:
a. The COBRA coverage start and
2. A copy of your health insurance
bills or COBRA payment coupons for each
month you are claiming the credit on
line 2.* The bills must have:
end dates;
payment for the June coverage for you
and your qualifying family members
b. Name of the health plan;
c. Your home address; and
d. Covered family members, their
dates of birth, their relationship to you, and
their social security numbers.
totaling $750, along with any other
a. Your name (or name of the policy
required documents. You don’t need to
attach documents for your July coverage.
holder),
b. The name of your health plan,
c. Your monthly premium amount,
d. Dates of coverage, and
Example 2. You checked March and
April on line 1. Your insurance coverage
for each month costs $750 ($500 for you
and $250 for your qualifying family
members). You paid $750 directly to your
health plan for each month. You would
include $1,500 on line 2 for the March and
April coverage. You must attach copies of
your health insurance bills and proof of
payment for the March and April coverage
for you and your qualifying family
3. A copy of “Notice of Rights to
Continue Coverage.”
e. Your health plan identification
Coverage through your spouse’s
employer. You must include the
and the following documents.
number(s).
*If your health plan doesn’t provide
members with an insurance bill or COBRA
payment coupon, you must provide health
plan enrollment documents or an official
letter from your health plan that has the
required information listed under items 2a
through 2e above. If your monthly
Copies of paycheck stubs showing the
•
health coverage deductions for each
month you are claiming the credit on
line 2.
members totaling $1,500 ($750 for each
month), along with any other required
documents.
A letter or other statement from your
•
spouse’s employer that states the
premium includes amounts that don’t
employer contributed less than 50% of the
Instructions for Form 8885 (2021)
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