Printable blank Form 14095

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1. What is a 14095 Form?

The fillable Form 14095 (The Health Coverage Tax Credit (HCTC) Reimbursement Request)  is a federal tax form by the Internal Revenue Service (IRS) that is designed to let taxpayers request reimbursement for premiums paid during the current year. You can use it if you have made at least 1 premium payment during the year and you qualify for the HCTC AMP (Advanced Monthly Payment). The form requires supporting docs (listed in Part IV of the form).

2. What I need the Form 14095 for?

This PDF form blank can be used for:

  • requesting reimbursement for your direct premium payments to particular health plans. 

You cannot request reimbursement if you are not permitted to take part in the  HCTC AMP program but made one or more premium payments. 

3. How to fill out Form 14095?

Before you start to fill this form, you may want to download Form 14095 from PDFLiner’s tax form library, or get it online to will out right away and print a complete form to sign and submit by mail. You can try all the options for free. 

In Part 1 of the form, provide the information to identify yourself, such as full name, SSN (Social Security Number), mailing address and phone number, and your HCTC participant identification number that you received in your 4545 Letter. 

In Part 2, you have to prove your eligibility. Check if all the statements in this part are true to qualify. A more detailed instruction is provided. Finally, Request reimbursement for particular months of the year, enter the totals for all the checked months, attach all the required documentation (see Part IV), and sign/date the form to validate it before mailing. 

It’s important to make sure that the IRS receives your complete 14095 copy before September 30 of the current calendar (not business) year. 

4. Organizations that work with Form 14095 

  • Internal Revenue Service;
  • Department of the Treasury.

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