Department of the Treasury - Internal Revenue Service
14765
Form
Employee Premium Tax Credit (PTC) Listing
(April 2017)
Any month not highlighted is a month that the employee received a PTC and no safe harbor or other relief from the ESRP was applicable. The employee is an assessable full-time
employee for that month.
Employer name
Employer ID number
Tax year
All 12 months
Indicator
Additional
SSN
Employee Name
Codes
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Information
(last 4
(last, first)
(Form 1095-C,
digits)
Attached
lines 14 and 16
combined)
14765
Catalog Number 68863V
www.irs.gov
Form
(4-2017)
Department of the Treasury - Internal Revenue Service
14765
Form
Employee Premium Tax Credit (PTC) Listing
(April 2017)
Any month not highlighted is a month that the employee received a PTC and no safe harbor or other relief from the ESRP was applicable. The employee is an assessable full-time
employee for that month.
Employer name
Employer ID number
Tax year
All 12 months
Indicator
Additional
SSN
Employee Name
Codes
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Information
(last 4
(last, first)
(Form 1095-C,
digits)
Attached
lines 14 and 16
combined)
14765
Catalog Number 68863V
www.irs.gov
Form
(4-2017)
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