This form contains 18 fields organized into 5 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name Type Description
Calculations
Subtract line 3 from line 2. Enter the result, but not less than zero 4 Text
Subtract the amount on line 3 from the amount on line 2. Enter the result, but not less than zero.
Claim Months
topmostSubform[0].Page1[0].c1_1[0]_1 CheckBox
Check this box if you are claiming the Health Coverage Tax Credit for January.
topmostSubform[0].Page1[0].c1_2[0]_1 CheckBox
Check this box if you are claiming the Health Coverage Tax Credit for February.
topmostSubform[0].Page1[0].c1_3[0]_1 CheckBox
Check this box if you are claiming the Health Coverage Tax Credit for March.
topmostSubform[0].Page1[0].c1_4[0]_1 CheckBox
Check this box if you are claiming the Health Coverage Tax Credit for April.
topmostSubform[0].Page1[0].c1_5[0]_1 CheckBox
Check this box if you are claiming the Health Coverage Tax Credit for May.
topmostSubform[0].Page1[0].c1_6[0]_1 CheckBox
Check this box if you are claiming the Health Coverage Tax Credit for June.
topmostSubform[0].Page1[0].c1_7[0]_1 CheckBox
Check this box if you are claiming the Health Coverage Tax Credit for July.
topmostSubform[0].Page1[0].c1_8[0]_1 CheckBox
Check this box if you are claiming the Health Coverage Tax Credit for August.
topmostSubform[0].Page1[0].c1_9[0]_1 CheckBox
Check this box if you are claiming the Health Coverage Tax Credit for September.
topmostSubform[0].Page1[0].c1_10[0]_1 CheckBox
Check this box if you are claiming the Health Coverage Tax Credit for October.
Eligibility
topmostSubform[0].Page1[0].c1_11[0]_1 CheckBox
Check this box if you are eligible to claim the Health Coverage Tax Credit (HCTC) for the specified month.
topmostSubform[0].Page1[0].c1_12[0]_1 CheckBox
Check this box if you are eligible to claim the Health Coverage Tax Credit (HCTC) for another specified month.
Financial Information
Enter the total amount of any Archer MSA or health savings accounts distributions used to pay for HCTC-qualified health insurance coverage for the months checked on line 1 3 Text
Enter the total amount of any Archer MSA or health savings accounts distributions used to pay for HCTC-qualified health insurance coverage for the months checked on line 1.
topmostSubform[0].Page1[0].f1_6[0 Text
Enter the total amount paid for health insurance coverage.
Personal Information
topmostSubform[0].Page1[0].f1_1[0 Text
Enter the recipient's full name.
Recipient's social security number Text
Enter the recipient's social security number. This should be a 9-digit number.
Max length: 11 characters
topmostSubform[0].Page1[0].f1_3[0 Text
Enter your personal information such as your name.