Form 14116 Family Member Eligibility Form

Form

Department of the Treasury - Internal Revenue Service

14116

OMB Number
1545-2163

HCTC Family Member Eligibility

(August 2013)

Part I: Provide Information About You
Name (First, Middle Initial, Last, Suffix)
Gender
Male

Social Security Number (SSN)

Your Date of Birth (mm/dd/yyyy)

Female

Your Primary Phone Number

Your Alternate Phone Number

Mailing Address (Street Number, City, State, ZIP code)

Part II: Provide Information About Your Family Member Who Was HCTC Eligible
Family Member Name (First, Middle Initial, Last, Suffix)
Family Member Date of Birth (mm/dd/yyyy)

Family Member Social Security Number

At the time of the event my family member was (Check One)
A Trade Adjustment Assistance (TAA), Alternative TAA, or Reemployment TAA recipient
A Pension Benefit Guaranty Corporation (PBGC) payee

Part III: Qualifying Event
Check the box below next to the qualifying event:
Death
Finalized a Divorce

Date of Qualifying Event (mm/dd/yyyy)

Part IV: Supporting Documentation
Please provide the HCTC Program with one of the following supporting documents:
• Final Divorce Decree
• Death Certificate
Please fax the completed form and supporting documents from a secure fax line to:
IRS - HCTC Program
Fax: 866-303-5298
Under penalties of perjury, I declare that the information furnished on this form with regard to myself and to any family member(s), and
any attachments to it, is true, correct, and complete. I understand that a knowing and willfully false statement on this form can result in
my disqualification from the monthly HCTC Program. By signing, I authorize the HCTC Program to independently discuss with my
health insurer, third party administrator or former employer, my eligibility status and HCTC payments made on my behalf to these
organizations.
Signature

Full Name (Print)

Date

PAPERWORK REDUCTION ACT NOTICE. We ask for the information on this form to carry out the Internal Revenue laws of the United States. Your
response is voluntary. You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the
form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become
material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by code section
6103. The estimated average time to complete this form is 15 minutes. If you have comments concerning the accuracy of this time estimate or
suggestions for making this form simpler, we will be happy to hear from you. You can write to the Tax Products Coordinating Committee, SE:W:CAR:
MP:T:T:SP, 1111 Constitution Ave. NW, Washington, DC 20224.
PRIVACY ACT STATEMENT. The following information is provided to comply with the Privacy Act of 1974 (P.L.93-579). All information collected on this
form is required under the provisions of 31 U.S.C. 3322 and 31 CFR 210. This information will be used by the Treasury Department to transmit payment
data, by electronic means to vendor’s financial institution. Failure to provide the requested information may delay or prevent the receipt of payments
through the Automated Clearing House Payment System.

Catalog Number 54355G

www.irs.gov

Form 14116 (Rev. 8-2013)