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Federal forms, ICRs, and supporting documents

Information Collection Request

Form 14095--The Health Coverage Tax Credit (HCTC) Reimbursement Request Form

ICR 201707-1545-017 · OMB 1545-2152 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form 14095 The Health Coverage Tax Credit (HCTC) Reimbursement Request Form Form and Instruction Modified Available
2017-10-03_SS_1545-2152r.docx Supporting Statement A Uploaded 2017-10-03 Available
IC Document Collections
IC IDCollectionTypeStatusForm
190222 The Health Coverage Tax Credit (HCTC) Reimbursement Request Form Form and Instruction Modified
ICR Details
1545-2152 201707-1545-017
Historical Active 201302-1545-006
TREAS/IRS
Form 14095--The Health Coverage Tax Credit (HCTC) Reimbursement Request Form
Reinstatement without change of a previously approved collection   No
Emergency 10/05/2017
Approved without change 12/18/2017
Retrieve Notice of Action (NOA) 10/05/2017
  Inventory as of this Action Requested Previously Approved
06/30/2018 6 Months From Approved
3,058 0 0
2,039 0 0
0 0 0
This form will be used by HCTC participants to request reimbursement for health plan premiums paid prior to the commencement of advance payments.
The Health Coverage Tax Credit (HCTC) was reauthorized into law June 29, 2015 and will remain in effect through December 31, 2019. The HCTC provides premium assistance for 72.5% of healthcare premiums. Per this legislation, taxpayers may request reimbursement credit of premiums. The taxpayers must file the Form 14095 with the IRS. The Form 14095 is used to request an HCTC reimbursement credit for premiums you paid directly to a qualified health plan while they were eligible and enrolling in the monthly HCTC Program. The taxpayer must be a Monthly HCTC Participant or have an HCTC registration in process for your request to be considered.
PL: Pub.L. 111 - 5 1899B Name of Law: American Recovery and Reinvestment Act of 2009
  
None
Not associated with rulemaking
  78 FR 19071 03/28/2013
No
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 3,058 0 0 3,058 0 0
Annual Time Burden (Hours) 2,039 0 0 2,039 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
Miscellaneous Actions
No
Submission request for reinstatement. The Health Coverage Tax Credit (HCTC) was reauthorized into law June 29, 2015 and will remain in effect through December 31, 2019.
$0
No
    Yes
    Yes
Yes
No
Yes
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.
10/05/2017