Form 8962 Premium Tax Credit (PTC)

Department of the Treasury 

Internal Revenue Service

▶ Attach to Form 1040, 1040A, or 1040NR.

▶ Information about Form 8962 and its separate instructions is at www.irs.gov/form8962.

OMB No. 1545-0074

2016

Attachment 

Sequence No. 73 

Name shown on your return Your social security number

You cannot claim the PTC if your filing status is married filing separately unless you qualify for an exception (see instructions). If you qualify, check the box.

Part I Annual and Monthly Contribution Amount 

1 Tax family size. Enter the number of exemptions from Form 1040 or Form 1040A, line 6d, or Form 1040NR, line 7d 1

2 a Modified AGI. Enter your modified 

AGI (see instructions) . . . . . 2a

b Enter the total of your dependents' 

modified AGI (see instructions) . . . 2b

3 Household income. Add the amounts on lines 2a and 2b (see instructions) . . . . . . . . . . . . 3

4 Federal poverty line. Enter the federal poverty line amount from Table 1-1, 1-2, or 1-3 (see instructions). Check the 

appropriate box for the federal poverty table used. a Alaska b Hawaii c Other 48 states and DC 4

5 Household income as a percentage of federal poverty line (see instructions) . . . . . . . . . . . . 5 %

6 Did you enter 401% on line 5? (See instructions if you entered less than 100%.)

No. Continue to line 7.

Yes. You are not eligible to take the PTC. If advance payment of the PTC was made, see the instructions for 

how to report your excess advance PTC repayment amount.

7 Applicable Figure. Using your line 5 percentage, locate your “applicable figure” on the table in the instructions . . 7

8 a Annual contribution amount. Multiply line 3 by 

line 7. Round to nearest whole dollar amount 8a

b Monthly contribution amount. Divide line 8a 

by 12. Round to nearest whole dollar amount 8b

Part II Premium Tax Credit Claim and Reconciliation of Advance Payment of Premium Tax Credit 

9 Are you allocating policy amounts with another taxpayer or do you want to use the alternative calculation for year of marriage (see instructions)? 

Yes. Skip to Part IV, Allocation of Policy Amounts, or Part V, Alternative Calculation for Year of Marriage. No. Continue to line 10.

10 See the instructions to determine if you can use line 11 or must complete lines 12 through 23.

Yes. Continue to line 11. Compute your annual PTC. Then skip lines 12–23 

and continue to line 24.

No. Continue to lines 12–23. Compute 

your monthly PTC and continue to line 24. 

Annual 

Calculation

(a) Annual enrollment

premiums (Form(s) 

1095-A, line 33A)

(b) Annual applicable 

SLCSP premium 

(Form(s) 1095-A, 

line 33B)

(c) Annual 

contribution amount 

(line 8a)

(d) Annual maximum 

premium assistance 

(subtract (c) from (b), if 

zero or less, enter -0-)

(e) Annual premium tax 

credit allowed 

(smaller of (a) or (d))

(f) Annual advance 

payment of PTC (Form

(s) 1095-A, line 33C)

11 Annual Totals

Monthly 

Calculation

(a) Monthly enrollment

premiums (Form(s) 

1095-A, lines 21–32, 

column A)

(b) Monthly applicable 

SLCSP premium (Form

(s) 1095-A, lines 21–32, 

column B)

(c) Monthly 

contribution amount 

(amount from line 8b 

or alternative marriage 

monthly calculation)

(d) Monthly maximum 

premium assistance 

(subtract (c) from (b), if 

zero or less, enter -0-)

(e) Monthly premium tax 

credit allowed 

(smaller of (a) or (d))

(f) Monthly advance 

payment of PTC (Form(s) 

1095-A, lines 21–32, 

column C)

12 January

13 February

14 March

15 April

16 May

17 June

18 July

19 August

20 September

21 October

22 November

23 December

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

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

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 

1040, line 69; Form 1040A, line 45; or Form 1040NR, line 65. If line 24 equals line 25, enter zero. Stop here. If line 25 is greater 

than line 24, leave this line blank and continue to line 27 . . . . . . . . . . . . . . . . . . . 26

Part III Repayment of Excess Advance Payment of the Premium Tax Credit

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

28 Repayment limitation (see instructions) . . . . . . . . . . . . . . . . . . . . . . 28

29 Excess advance premium tax credit repayment. Enter the smaller of line 27 or line 28 here and on Form 1040, line 

46; Form 1040A, line 29; or Form 1040NR, line 44 . . . . . . . . . . . . . . . . . . . 29

For Paperwork Reduction Act Notice, see your tax return instructions. Cat. No. 37784Z Form 8962 (2016) 
Form 8962 (2016) Page 2 

Part IV Allocation of Policy Amounts

Complete the following information for up to four shared policy allocations. See instructions for allocation details.

Allocation 1

30 (a) Policy Number (Form 1095-A, line 2) (b) SSN of other taxpayer (c) Allocation start month (d) Allocation stop month

Allocation percentage 

applied to monthly 

amounts

(e) Premium Percentage (f) SLCSP Percentage (g) Advance Payment of the PTC 

Percentage 

Allocation 2

31 (a) Policy Number (Form 1095-A, line 2) (b) SSN of other taxpayer (c) Allocation start month (d) Allocation stop month

Allocation percentage 

applied to monthly 

amounts

(e) Premium Percentage (f) SLCSP Percentage (g) Advance Payment of the PTC 

Percentage 

Allocation 3

32 (a) Policy Number (Form 1095-A, line 2) (b) SSN of other taxpayer (c) Allocation start month (d) Allocation stop month

Allocation percentage 

applied to monthly 

amounts

(e) Premium Percentage (f) SLCSP Percentage (g) Advance Payment of the PTC 

Percentage 

Allocation 4

33 (a) Policy Number (Form 1095-A, line 2) (b) SSN of other taxpayer (c) Allocation start month (d) Allocation stop month

Allocation percentage 

applied to monthly 

amounts

(e) Premium Percentage (f) SLCSP Percentage (g) Advance Payment of the PTC 

Percentage 

34 Have you completed all policy amount allocations?

Yes. Multiply the amounts on Form 1095-A by the allocation percentages entered by policy. Add all allocated policy amounts and nonallocated policy amounts from Forms 1095-A, if any, to compute a combined total for each month. Enter the combined total for each month on 

lines 12–23, columns (a), (b), and (f). Compute the amounts for lines 12–23, columns (c)–(e), and continue to line 24.

No. See the instructions to report additional policy amount allocations.

Part V Alternative Calculation for Year of Marriage

Complete line(s) 35 and/or 36 to elect the alternative calculation for year of marriage. For eligibility to make the election, see the instructions for line 9. 

To complete line(s) 35 and/or 36 and compute the amounts for lines 12–23, see the instructions for this Part V.

35 Alternative entries 

for your SSN

(a) Alternative family size (b) Alternative monthly 

contribution amount

(c) Alternative start month (d) Alternative stop month

36 

 

Alternative entries 

for your spouse's 

SSN

(a) Alternative family size (b) Alternative monthly 

contribution amount

(c) Alternative start month (d) Alternative stop month

Form 8962 (2016)