Instructions For Form 13441-A - Health Coverage Tax Credit (Hctc) Monthly Registration And Update
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4Department of the Treasury
Instructions for Form 13441-A
Internal Revenue Service
(Rev. January 2016)
Health Coverage Tax Credit (HCTC)
Monthly Registration and Update
General Instructions
Please read carefully and follow the instructions below to complete Form 13441-A. Write your Social Security Number
at the top of each document you are sending to the HCTC Program. Print or type your responses. To register for the
Monthly HCTC, you must complete the following steps:
1. Collect the documents you will need to submit with your HCTC Monthly Registration Form. See the “Required
Supporting Documents” section for a detailed list of the required documents.
2. Fill out the HCTC Monthly Registration Form.
3. Make a copy of the completed HCTC Monthly Registration Form and all required documents for your records.
4. Mail the completed HCTC Monthly Registration Form and all required documents to:
Internal Revenue Service
Stop 6098 AUSC
Austin, Texas 78741
5. Check here if you are registering as a Qualified Family Member. Note: Qualified Family members of HCTC eligible
individuals may receive the HCTC for up to 24 months following the eligible individual’s Medicare enrollment, death
or divorce.
6. Check here if you are updating your current monthly registration. When you are enrolled in the monthly HCTC
Program, you must inform us of all changes that affect your eligibility, your family members and your health
insurance. You only need to provide the updated information.
7. Please note that once you mail the registration form, it can take up to 6 weeks
before you
(if all requirements are met)
receive registration confirmation. During this time, you must continue to pay your health insurance bills directly to
your health plan and keep records of your payments. You can claim the yearly tax credit for these and any months
that you met all eligibility requirements and made payments directly to a qualified health plan.
Required Supporting Document
The following document is required to be submitted with your HCTC Monthly Registration Form. Review the required
document checklist carefully. Caution: An incomplete form or missing documents will delay the processing of your
registration.
A copy of your health insurance bill dated within the last 60 days that includes all of the following:
• Your name
• Health Plan Administrator name and phone number
• Monthly premium amount
• Health plan identification numbers
• Dates of coverage
• Address for mailing your payments
If applicable, your bill must show the following:
• Dollar amount for family members who are not qualified for the HCTC
• Separate dollar amount for benefits that the HCTC does not cover
(such as separate dental or vision plans)
Usually, your health insurance bill will have all this information on it. If it does not, you will need a letter or another
document from your Health Plan Administrator that includes this information.
13441-A
Catalog Number 57559E
Form
(Rev. 1-2016)
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