| 1 |
Monthly SLCSP Premium |
Enter the monthly amounts for the applicable Second Lowest Cost Silver Plan (SLCSP) for each individual (Column (a)). |
| 2 |
Monthly Contribution Amount |
Enter the monthly contribution amount for each individual (Column (b)). |
| 3 |
Premium Assistance Amount |
Calculate the premium assistance amount for each month (Column (c)). This is the difference between the SLCSP premium and the individual's contribution. |
| 4 |
Total Premium Assistance Amount |
The sum of the premium assistance amounts for the year. |
| 5 |
Annual Contribution Amount |
The sum of the monthly contribution amounts for the year. |
| 6 |
Net Premium Tax Credit |
Calculate the net premium tax credit (Line 4 minus Line 5). |
| 7 |
Repayment Limitation |
Calculate the repayment limitation based on income (Line 12). |
| 8 |
Excess Advance Premium Tax Credit Repayment |
Calculate the excess advance premium tax credit repayment (Lines 13-23). This is the amount to be repaid if the actual credit received exceeds the allowable credit. |
| 9 |
Net Premium Tax Credit After Repayment |
Calculate the net premium tax credit after repayment (Line 6 minus Line 8). |
