2021 Form 8885 (PDF)

Official source: IRS Forms, Instructions & Publications (https://www.irs.gov/pub/irs-pdf/f8885.pdf), retrieved 2026-10-03. U.S. Government work (17 U.S.C. § 105).

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Form

Internal Revenue Service - Go to www.irs.gov/Form8885 for instructions and the latest information. Sequence No. 134

Name of recipient (if both spouses are recipients, complete a separate form for each spouse) Recipient’s social security number

Department of the Treasury Internal Revenue Service

• Go to www.irs.gov/Form8885 for instructions and the latest information.

• Attach to Form 1040, 1040-SR, 1040-NR, 1040-SS, or 1040-PR.

Before you begin: See Definitions and Special Rules in the instructions.

CAUTION

Do not complete this form if you can be claimed as a dependent on someone else’s 2021 tax return.

Part I Election To Take the Health Coverage Tax Credit 1 Check the box below for the first month in your tax year that you elect to take the Health Coverage Tax Credit (HCTC). All of the following statements must be true as of the first day of that month. You must also check the box for each month after your election month that all of the following statements were true as of the first day of that month.

• You were an eligible trade adjustment assistance (TAA) recipient, alternative TAA (ATAA) recipient, reemployment TAA (RTAA)

recipient, or Pension Benefit Guaranty Corporation (PBGC) payee; or you were a qualifying family member of an individual who fell under one of the categories listed above when he or she passed away or with whom you finalized a divorce.

• You and/or your family member(s) were covered by HCTC-qualified health insurance coverage for which you paid the entire

premiums, or your portion of the premiums, directly to your health plan or to “US Treasury-HCTC.”

• You were not enrolled in Medicare Part A, B, or C, or you were enrolled in Medicare but your family member(s) qualified for

the HCTC.

• You were not enrolled in Medicaid or the Children’s Health Insurance Program (CHIP).

• You were not enrolled in the Federal Employees Health Benefits Program (FEHBP) or eligible to receive benefits under the U.S. military health system (TRICARE).

• You were not imprisoned under federal, state, or local authority.

• Your or your spouse ’ s employer (or former employer) did not pay 50% or more of the cost of coverage.

• You did not receive a 100% COBRA premium reduction from your former employer or COBRA administrator.

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