Marco and Tracy Brigante live in California, are married filing jointly, under age 65, and have three children ages 14, 16, and 26; however, the oldest child is not claimed as a dependent and does not live at home. Tracy’s adjusted gross income is $44,040 and Marco’s is $22,000 and both are self-employed. They also have $2,000 in interest income from tax-exempt bonds. The Brigantes are enrolled in health insurance for all of 2017 through their state exchange and elected to have the credit paid in advance.

Using the Brigante’s 2017 Form 1095-A (click here to access the completed Form 1095-A), complete the Form 8962.

Round your final answers to the nearest dollar. For line 5, round to two decimal place before converting to a percent. Enter as a percent and not a decimal. For example: 1.35 would be entered as 135. For line 7 on Form 8962, enter the amount as shown on the 2017 Applicable Figure Table.

Table for Federal Poverty Line 

Persons in Family/Household	2016 FPL for 48 States and DC
1	$11,880
2	16,020
3	20,160
4	24,300
5	28,440
6	32,580
7	36,730
8	40,890
Each additional person	+$ 4,160
The household income is then expressed as a percentage of the FPL.

Table for Repayment of the Credit Amount 

	Single	Taxpayers Other Than Single
Less than 200%	$300	$600
At least 200% but less than 300%	750	1,500
At least 300% but less than 400%	1,275	2,550
At least 400%	No limit	No limit

 

Click here to access the 2017 Applicable Figure Table to use for this problem.

Complete the Form 8962 to determine (1) the actual premium tax credit, (2) the excess advance payment, and (3) the repayment amount required. Enter all amounts as positive numbers. 

Form 8962  Department of the Treasury Internal Revenue Service	Premium Tax Credit (PTC) ► Attach to Form 1040, 1040A, or 1040NR.  ► Go to www.irs.gov/Form8962 for the instructions and latest information.	OMB No. 1545-0074
		2017 Attachment Sequence No. 73

Name(s) shown on return Tracy and Marco Brigante	Your social security number 123-44-5555
You cannot claim the PTC if your filing status is married filing separately unless you are eligible 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
2a	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
8a	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 contribution)	(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 you elected the alternative calculation for marriage, enter zero. 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 (2017)