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I understand that the tax credit recipient must comply with Oregon Department of Revenue requirements to document that the credit has been appropriately assigned, allocated or transferred, and claimed, and that compliance is subject to audit. . I understand that this tax credit application is a public record and that Oregon Department of Energy may be required by law to disclose information in this tax credit application to the public on request. I have marked any information that I request be kept confidential. I understand that marking information does not guarantee that it will be kept confidential and that the Director. | Form 8885 Department of the Treasury Internal Revenue Service Health Coverage Tax Credit Attach to Form 1040 Form 1040NR Form 1040-SS or Form 1040-PR Information about Form 8885 and its instructions is at www.irs.gov form8885. OMB No. 1545-0074 2012 Attachment Sequence No. 134 Name of recipient if both spouses are recipients complete a separate form for each spouse Recipient s social security number Before you begin See Definitions and Special Rules in the instructions. Do not complete this form if you can be claimed as a dependent on someone else s 2012 tax return. CAUTION Part I Complete This Part To See if You Are Eligible To Take This Credit_ 1 Check the boxes below for each month in 2012 that all of the following statements were true on 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 pension payee or you were a qualified 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 a qualified health insurance plan for which you paid the entire premiums or your portion of the premiums directly to your health plan or to U.S. 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 employer did not pay 50 or more of the cost of coverage. You did not receive a 65 COBRA premium reduction from your former employer or COBRA administrator. Part II 2 3 .