Fillable Form 8962 (2021)

What is Form 8962?

Form 8962, Premium Tax Credit (PTC), is used to determine the amount of a taxpayer’s premium tax credit (PTC) and reconcile it with advance payment of the premium tax

credit (APTC). A taxpayer may take the PTC and his or her APTC may be paid only for health insurance coverage in a qualified health plan purchased through a Health Insurance Marketplace, or also referred to as an Exchange. As a result, a taxpayer should complete Form 8962 only for health insurance coverage in a qualified health plan purchased through a Marketplace.

How to fill out Form 8962?

Applicants can download and print a PDF copy of Form 8962 from the Internal Revenue Service (IRS) website that they can manually complete. They can also fill out Form 8962 electronically on PDFRun.

To fill out Form 8962, you must provide the following information:

Item A

Mark the box if you or your spouse, if you are filing a joint return, received or were approved to receive unemployment compensation for any week beginning during the year 2021.

Item B

Mark the box if you qualify for an exception even though you cannot take the Premium Tax Credit (PTC) because your filing status is “married filing separately”.

Part I. Annual and Monthly Contribution Amount

Line 1

Enter your appropriate tax family size.

Line 2a

Enter the total amount of your modified adjusted gross income (AGI).

Line 2b

Enter the total amount of your dependents’ modified adjusted gross income (AGI).

Line 3

Enter the total amount of your household income by adding the amounts in lines 2a and 2b.

Line 4

Enter your federal poverty line. Then, mark the appropriate box which corresponds to the federal poverty table you have used. You may select:

a. Alaska

b. Hawaii

c. Other 48 states and District of Columbia (DC)

Line 5

Enter your household income as a percentage of the federal poverty line.

Line 6

This space is reserved for future use and must be left blank.

Line 7

Enter your applicable figure by using the percentage in line 5 and locating the figure in the table.

Line 8a

Enter the total amount of your annual contribution by multiplying the amount in line 3 by the amount in line 7. You must round the amount up to the nearest whole dollar amount.

Line 8b

Enter the total amount of your monthly contribution by dividing the amount in line 8a by 12. You must round the amount up to the nearest whole dollar amount.

Part II. Premium Tax Credit Claim and Reconciliation of Advance Payment of Premium Tax Credit

Line 9

Mark YES if you are allocating policy amounts with another taxpayer or you would like to use the alternative calculation for the year of marriage; otherwise, mark NO.

If you have marked YES, skip to part IV, Allocation of Policy Amounts or Part V, Alternative Calculation for Year of Marriage. If you have marked NO, continue to line 10.

Line 10

Mark YES if you can use line 11 or if you must complete lines 12 through 23.

If you marked YES, continue to line 11 and compute your annual Premium Tax Credit (PTC). Then, skip lines 12 through 23.

Annual Calculation

Line 11

Enter your annual calculation for the following payments:

a. Annual enrollment premiums - Form 1095-A, Health Insurance Marketplace Statement, line 33A

b. Annual applicable Second Lowest Cost Silver Plan (SLCSP) premium - Form 1095-A, Health Insurance Marketplace Statement, line 33B

c. Annual contribution amount

d. Annual maximum premium assistance

e. Annual premium tax credit allowed

f. Annual advance payment of Premium Tax Credit (PTC) - Form 1095-A, Health Insurance Marketplace Statement, line 33C

Monthly Calculation

Enter your monthly calculations for the following payments:

a. Monthly enrollment premiums - Form 1095-A, Health Insurance Marketplace Statement, lines 21 to 32, column A

b. Monthly applicable Second Lowest Cost Silver Plan (SLCSP) premium - Form 1095-A, Health Insurance Marketplace Statement, lines 21 to 32, column B

c. Monthly contribution amount

d. Monthly maximum premium assistance

e. Monthly premium tax credit allowed

f. Monthly advance payment of Premium Tax Credit (PTC) - Form 1095-A, Health Insurance Marketplace Statement, line 21 to 32, column C

Line 12

Enter your monthly calculation for the month of January.

Line 13

Enter your monthly calculation for the month of February.

Line 14

Enter your monthly calculation for the month of March.

Line 15

Enter your monthly calculation for the month of April.

Line 16

Enter your monthly calculation for the month of May.

Line 17

Enter your monthly calculation for the month of June.

Line 18

Enter your monthly calculation for the month of July.

Line 19

Enter your monthly calculation for the month of August.

Line 20

Enter your monthly calculation for the month of September.

Line 21

Enter your monthly calculation for the month of October.

Line 22

Enter your monthly calculation for the month of November.

Line 23

Enter your monthly calculation for the month of December.

Line 24

Enter the total amount of your premium tax credit (PTC) by adding the amounts in lines 12 (e) through 23(e).

Line 25

Enter the total amount of the advance payment for your premium tax credit (PTC) by adding the amounts in lines 12(f) through 23(f).

Line 26

Enter the total amount of your net premium tax credit (PTC).

If the amount in line 24 is greater than the one in line 25, subtract the amount in line 25 from the one in line 24.

Part III. Repayment of Excess Advance Payment of the Premium Tax Credit

Line 27

Enter any excess advance you may have for your premium tax credit (PTC).

If the amount in line 24 is greater than the one in line 25, subtract the amount in line 25 from the one in line 24.

Line 28

Enter any repayment limitation you may have.

Line 29

Enter any excess advance premium tax credit (PTC) payment by entering the smaller amount between lines 27 and 28.

Part IV. Allocation of Policy Amounts

Enter the following information about your policy amount allocations. The instructions here will apply to lines 31 through 33.

a.Policy Number - Enter your policy number.

b.Social Security Number (SSN) of other taxpayer - Enter the social security number (SSN) of the other taxpayer.

c.Allocation start month - Enter the month when the allocation starts.

d.Allocation stop month - Enter the month when the allocation must stop.

Allocation percentage applied to monthly amounts

a.Premium Percentage - Enter your premium percentage.

b.Second Lowest Cost Silver Plan (SLCSP) Percentage - Enter your Second Lowest Cost Silver Plan (SLCSP) percentage.

c. Advance Payment of the Premium Tax Credit (PTC) Percentage - Enter your advance payment of the premium tax credit (PTC) percentage.

Line 34

Mark YES if you have completed all of the policy amount allocations; otherwise, mark NO.

If you have marked YES, multiply the amounts in Form 1095-A, Health Insurance Marketplace Statement by the allocation percentages entered by policy. Then, add all allocated policy amounts and non-allocated policy amounts from Forms 1095-A to compute a combined total for each month. Enter the combined total for each month on lines 12 to 23, columns (a), (b), and (f). Compute the amounts for lines 12 to 23, columns (c) to (e) then continue to line 24.

If you have marked NO, enter any additional policy amount allocations.

Part V. Alternative Calculation for Year of Marriage

The instructions here will apply to both lines 35 and 36. Enter the following information:

a. Alternative family size

b. Alternative monthly contribution amount

c. Alternative start month

d. Alternative stop month