OMB control number
State Election of Qualified Health Insurance for Health Coverage Tax Credit (HCTC)
OMB 1545-1875 · TREAS/IRS.
OMB 1545-1875
Revenue Procedure 2004-12 informs states how to elect a health program to be qualified health insurance for purposes of the health coverage tax credit (HCTC) under section 35 of the Internal Revenue Code. The collection of information is voluntary. However, if a state does not make an election, eligible residents of the state may be impeded in their efforts to claim the HCTC.
The latest form for State Election of Qualified Health Insurance for Health Coverage Tax Credit (HCTC) expires 2021-05-31 and can be found here.
Latest Forms, Documents, and Supporting Material
Document Name |
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Supporting Statement A |
1545-1875 SS (Rev. Proc. 2004-12) 2021-05-28.docx
Health Insurance Costs of Eligible Individuals All Historical Document Collections
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Approved without change |
Extension without change of a currently approved collection | 2021-05-28 | |
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Approved without change |
Extension without change of a currently approved collection | 2020-03-31 | |
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Approved without change |
Extension without change of a currently approved collection | 2016-12-19 | |
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Approved without change |
Extension without change of a currently approved collection | 2013-09-30 | |
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Approved without change |
Extension without change of a currently approved collection | 2010-07-26 | |
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Approved without change |
Extension without change of a currently approved collection | 2007-04-26 | |
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Approved without change |
Extension without change of a currently approved collection | 2004-04-28 | |
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Approved without change |
New collection (Request for a new OMB Control Number) | 2004-01-16 |