Form  
8885
Department of the Treasury  
Internal Revenue Service 
Health Coverage Tax Credit
a
 Attach to Form 1040, Form 1040NR, Form 1040-SS, or Form 1040-PR.
a
 
.
OMB No. 1545-0074
20
13
Attachment 
Sequence No. 
134
Name of recipient (if both spouses are recipients, complete a separate form for each spouse)
Recipient•s social security number
Before you begin: 
See 
Definitions and Special Rules 
in the instructions.
F
!
CAUTION
Do not 
complete this form if you can be claimed as a dependent on someone else’s 2013 tax return.
Part I
Complete This Part To See if You Are Eligible To Take This Credit
1
Check the boxes below for each month in 2013 that 
all 
of the following statements were 
true 
on the 
first day 
of that month.
• You were an eligible trade adjustment assistance (TAA) recipient, alternative TAA (ATAA) recipient, reemployment TAA (RTAA) 
recipient, or Pension Benefit Guaranty Corporation (PBGC) pension payee; or you were a qualified family member of an
individual who fell under one of the categories listed above when he or she passed away or with whom you finalized 
a divorce. 
• You and/or your family member(s) were covered by a qualified health insurance plan for which you paid the entire premiums, 
or your portion of the premiums, directly to your health plan or to “U.S. Treasury–HCTC.”
• You were 
not 
enrolled in Medicare Part A, B, or C, or you were enrolled in Medicare but your family member(s) qualified for 
the HCTC.
• You were 
not 
enrolled in Medicaid or the Children’s Health Insurance Program (CHIP).
• You were 
not 
enrolled in the Federal Employees Health Benefits Program (FEHBP) or eligible to receive benefits under the
U.S. military health system (TRICARE).
• You were 
not 
imprisoned under federal, state, or local authority.
• Your employer 
did not
 pay 50% or more of the cost of coverage.
• You 
did not 
receive a 65% COBRA premium reduction from your former employer or COBRA administrator.
January
February
March
April
May
June
July
August
September
October
November
December
Part II
Health Coverage Tax Credit
2
Enter the total amount paid directly to your health plan for qualified health insurance coverage for 
the months checked on line 1 (see instructions). 
Do not 
include on line 2 any qualified health
insurance premiums paid to “U.S. Treasury–HCTC” or any insurance premiums on coverage that 
was actually paid for with a National Emergency Grant. Also, 
do not 
include any advance 
(monthly) payments or reimbursement credits you received as shown on Form 1099-H, box 1  .    .
2
F
!
CAUTION
You 
must 
attach the required documents listed in the instructions for any amounts
included on line 2. If you do not attach the required documents, your credit will be
disallowed.
3
Enter the total amount of any Archer MSA or health savings accounts distributions used to pay for 
qualified health insurance coverage for the months checked on line 1   .    .    .
........
3
4
Subtract line 3 from line 2. If zero or less, 
stop;
you cannot take the credit 
........
4
5 
 
Health Coverage Tax Credit. 
If you received an advance (monthly) payment in any month not 
checked on line 1, see the instructions for line 5 for more details. Otherwise, multiply the amount 
on line 4 by 72.5% (.725). Enter the result here and on Form 1040, line 71 (check box
 c
); Form
1040NR, line 67
 
(check box 
c
); Form 1040-SS, line 10; or Form 1040-PR, line 10 
......
5 
For Paperwork Reduction Act Notice, see your tax return instructions.
Cat. No. 34641D
Form 
8885
 (2013)
Information about Form 8885 and its instructions is at www.irs.gov/form8885
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