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Form 8962 <br />Department of the Treasury <br />Internal Revenue Service <br />Premium Tax Credit (PTC) <br /> Attach to Form 1040, 1040A, or 1040NR. <br /> Go to www.irs.gov/Form8962 for instructions and the latest information. <br />OMB No. 1545-0074 <br />Attachment <br />Sequence No. 73 <br />Name shown on your return Your social security number <br />You cannot take the PTC if your filing status is married filing separately unless you qualify for an exception (see instructions). If you qualify, check the box <br />Part I <br />1 Tax family size. Enter the number of exemptions from Form 1040 or Form 1040A, line 6d, or Form 1040NR, line 7d 1 <br />2 a 2a <br />b 2b <br />3 Household income. Add the amounts on lines 2a and 2b (see instructions)3 <br />4 Federal poverty line. Enter the federal poverty line amount from Table 1-1, 1-2, or 1-3 (see instructions). Check the <br />appropriate box for the federal poverty table used. a Alaska b Hawaii c Other 48 states and DC 4 <br />5 Household income as a percentage of federal poverty line (see instructions)5 % <br />6 Did you enter 401% on line 5? (See instructions if you entered less than 100%.) <br />No. Continue to line 7. <br />Yes. You are not eligible to take the PTC. If advance payment of the PTC was made, see the instructions for how <br />to report your excess advance PTC repayment amount. <br />7 Applicable Figure. Using your line 5 percentage, locate your "applicable figure" on the table in the instructions 7 <br />8 a Annual contribution amount. Multiply line 3 <br />8a <br />b <br /> <br />Monthly contribution amount. Divide line 8a by <br />12. Round to nearest whole dollar amount 8b <br />Part II <br />9 Are you allocating policy amounts with another taxpayer or do you want to use the alternative calculation for year of marriage (see instructions)? <br />Yes. No. <br />10 <br />Yes. Continue to line 11. Compute your annual PTC. Then skip lines 12-23 <br />and continue to line 24. <br />No. Continue to lines 12-23. Compute <br />your monthly PTC and continue to line 24. <br />Annual <br />Calculation <br />(a) (b) Annual applicable <br />SLCSP premium <br />(Form(s) 1095-A, <br />line 33B) <br />(c) Annual <br />contribution amount <br />(line 8a) <br />(d) Annual maximum <br />premium assistance <br />(subtract (c) from (b), if <br />(e) Annual premium <br />tax credit allowed <br />(smaller of (a) or (d)) <br />(f) Annual advance <br />payment of PTC <br />(Form(s) 1095-A, line <br />33C) <br />11 Annual Totals <br />Monthly <br />Calculation <br />(a) (b) (c) Monthly <br />contribution amount <br />(amount from line 8b <br />or alternative marriage <br />monthly calculation) <br />(d)(e)(f) Monthly advance <br />payment of PTC <br />(Form(s) 1095-A, lines <br />21-32, column C) <br />12 January <br />13 February <br />14 March <br />15 April <br />16 May <br />17 June <br />18 July <br />19 August <br />20 September <br />21 October <br />22 November <br />23 December <br />24 Total premium tax credit. Enter the amount from line 11(e) or add lines 12(e) through 23(e) and enter the total here 24 <br />25 Advance payment of PTC. Enter the amount from line 11(f) or add lines 12(f) through 23(f) and enter the total here 25 <br />26 Net premium tax credit. If line 24 is greater than line 25, subtract line 25 from line 24. Enter the difference here and on Form <br />1040, line 69; Form 1040A, line 45; or Form 1040NR, line 65. If line 24 equals line 25, enter -0-. Stop here. If line 25 is greater <br />than line 24, leave this line blank and continue to line 27 26 <br />Part III <br />27 Excess advance payment of PTC. If line 25 is greater than line 24, subtract line 24 from line 25. Enter the difference here 27 <br />28 <br /> <br />Repayment limitation (see instructions)28 <br />29 <br /> <br />Excess advance premium tax credit repayment. Enter the smaller of line 27 or line 28 here and on Form 1040, line <br />46; Form 1040A, line 29; or Form 1040NR, line 44 29 <br />For Paperwork Reduction Act Notice, see your tax return instructions. Form 8962 (2017) <br />2017 <br />UYA <br />Premium Tax Credit Claim and Reconciliation of Advance Payment of Premium Tax Credit <br />Annual and Monthly Contribution Amount <br />zero or less, enter -0-) <br />Repayment of Excess Advance Payment of the Premium Tax Credit <br /> Continue to line 10. <br />Modified AGI. Enter your modified AGI (see instructions) <br />Enter the total of your dependents' modified AGI (see instructions) <br />Wesley C Brown and Shanon M Larimer 595-42-0794 <br />3 <br />67,966. <br />67,966. <br />X 20,160. <br />337 <br />X <br />0.0969 <br />6,586.549. <br />X <br />X <br />12,913. 8,610. 6,586. 2,024. 2,024. 5,352. <br />2,024. <br />5,352. <br />3,328. <br />2,550. <br />2,550.