Form 13441, Health Coverage Tax Credit Registration Form, will be directly mailed to all individuals who are potentially eligible for the HCTC. Potentially eligible individuals will use this form to determine if they are eligible for the Health Coverage Tax Credit and to register for the HCTC program. Participation in this program is voluntary. This form will be submitted by the individual to the HCTC program office in a postage-paid, return envelope. We will accept faxed forms, if necessary. Additionally, recipients may call center for help in completing this form.
Form 13441 is used to determine if taxpayers are eligible for the Health Coverage Tax Credit and to register for the HCTC program.
Form 13441-EZ is a simplified version of Form 13441 and will be used for a streamlined batch process to register groups of individuals for the monthly HCTC Program.
The creation of the new form 13441-EZ will result in an increase in the number of responses by 3,600 and a total of 900 burden hours.
$65,000
No
No
No
Uncollected
No
Uncollected
Lynn Reno 2022839639
No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control number;
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
Form 13441 Health Coverage Tax Credit Registration Form
Summary of Changes.pdf
Health Coverage Tax Credit Registration Form