UIPL2-03_AttachC.pdf

ETA Advisory File Text

Proof as of Sept. 27 2002 subject to change Department of the Treasury - Internal Revenue ServiceCat. No. 34756D Page 1 of x of Form 8887 Page x is BLANK. 4 The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing. TLS have you transmitted all R text files for this cycle update DateDate Action Revised proofs requested Date Signature O.K. to print T FP F O.K. to print Responsible scan organization ISSUER S name street address city state ZIP code and telephone no. OMB No. 1545-xxxx Health Insurance Credit Eligibility Certificate ISSUER S Federal identification numberRECIPIENT S identification number Recipient is an eligible RECIPIENT S name Street address including apt. no. City state and ZIP code For optional use by issuer Form8887 2002 Copy A You may be able to claim the health insurance credit for eligible recipients. See Form 8885 for details. For Recipient keep for your records Form 8887 2002 TAA or alternative TAA recipient PBGC pension recipient P oof as of Sept. 27 2002 subject to change 4 The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing. Department of the Treasury - Internal Revenue Service ISSUER S name street address city state ZIP code and telephone no. OMB No. 1545-xxxx Health Insurance Credit Eligibility Certificate ISSUER S Federal identification numberRECIPIENT S identification number Recipient is an eligible RECIPIENT S name Street address including apt. no. City state and ZIP code For optional use by issuer Form8887 2002 Copy B For Paperwork Reduction Act Notice see instructions. For Issuer Form 8887 2002 TAA or alternative TAA recipient PBGC pension recipient Page X of X of Form 8887 r Proof as of Sept. 27 2002 subject to change Instructions for Issuers Use Form 8887 to notify a trade adjustment assistance TAA alternative TAA or Pension Benefit Guaranty Corporation PBGC pension recipient that he or she may qualify for the health insurance credit for eligible recipients claimed on Form 8885. Due Date The time needed to complete and file this form will vary depending on individual circumstances. The estimated average time is Recordkeeping XX min. Learning about the law or the form XX min. Preparing the form XX hr. XX min. and Copying assembling and sending the form to the IRS XX min. Page X of X of Form 8887 4 The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing. Printed on recycled paper Purpose of Form Paperwork Reduction Act Notice. We ask for the information on this form to carry out the Internal Revenue laws of the United States. If you use Form 8887 you must provide the requested information. Your cooperation will help us ensure that we are collecting the right amount of tax. You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally tax returns and return information are confidential as required by Internal Revenue Code section 6103. Furnish Copy A of this form to the recipient by February 18 2003. If you have comments concerning the accuracy of these time estimates or suggestions for making this form simpler we would be happy to hear from you. You can write to the Tax Forms Committee Western Area Distribution Center Rancho Cordova CA 95743-0001. Do not send the form to this address. Who Must File Form 8887 should be completed only by an authorized representative of a state or the PBGC.