8962 Form 2015

For Paperwork Reduction Act Notice see your tax return instructions. Cat. No. 37784Z Form 8962 2015 Page Shared Policy Allocation Complete the following information for up to four shared policy allocations. Form OMB No* 1545-0074 Premium Tax Credit PTC Department of the Treasury Internal Revenue Service Name shown on your return Attach to Form 1040 1040A or 1040NR* Information about Form 8962 and its separate instructions is at www*irs*gov/form8962. Attachment Sequence No* 73 Your social security number You cannot claim the PTC if your filing status is married filing separately unless you are eligible for an exception see instructions. If you qualify check the box. Part I Annual and Monthly Contribution Amount Tax family size. Enter the number of exemptions from Form 1040 or Form 1040A line 6d or Form 1040NR line 7d 2a Modified AGI. Enter your modified AGI see instructions. Household income. Add the amounts on lines 2a and 2b. b Enter the total of your dependents modified AGI see instructions. Federal poverty line. Enter the federal poverty line amount from Table 1-1 1-2 or 1-3 see instructions. Check the appropriate box for the federal poverty table used* a Alaska b Hawaii c Other 48 states and DC. Did you enter 401 on line 5 See instructions if you entered less than 100. 2b No* Continue to line 7. Yes. You are not eligible to receive PTC. If advance payment of the PTC was made see the instructions for how to report your excess advance PTC repayment amount. Applicable Figure. Using your line 5 percentage locate your applicable figure on the table in the instructions 8a Annual contribution amount. Multiply line 3 by line 7. b Monthly contribution amount. Divide line 8a by 12. Round to whole dollar amount 8b Are you allocating policy amounts with another taxpayer or do you want to use the alternative calculation for year of marriage see instructions Yes. Skip to Part IV Shared Policy Allocation or Part V Alternative Calculation for Year of Marriage. See the instructions to determine if you can use line 11 or must complete lines 12 through 23. Yes. Continue to line 11. Compute your annual PTC. Then skip lines 12 23 your monthly PTC and continue to line 24. and continue to line 24. Annual Calculation a Annual enrollment premiums Form s 1095-A line 33A b Annual applicable SLCSP premium Form s 1095-A line 33B d Annual maximum premium assistance subtract c from b if zero or less enter -0- contribution amount line 8a e Annual premium tax f Annual advance credit allowed payment of PTC Form smaller of a or d Annual Totals Monthly a Monthly enrollment b Monthly applicable 1095-A lines 21 32 s 1095-A lines 21 32 column A amount from line 8b or alternative marriage d Monthly maximum f Monthly advance e Monthly premium tax January February March April May June July August September October November December Total premium tax credit. Enter the amount from line 11 e or add lines 12 e through 23 e and enter the total here Advance payment of PTC. Enter the amount from line 11 f or add lines 12 f through 23 f and enter the total here Net premium tax credit.