Advance Premium Tax Credit (APTC) Adjustment Form

Advance Premium Tax Credit (APTC) Adjustment Form

Each care provider in the household needs to complete their own form.
Securely manage your benefits online with MyCarewell503. Starting July 1, 2024, the English version of this form will be available exclusively on MyCarewell503. Learn more.
When you file your income tax return, the Internal Revenue Service (IRS) will compare the amount of tax credits you received in that year with the amount of tax credits you should have received. The tax credit amount you should have received is based on the estimated income you reported on your Marketplace application.

Use this form:
- If your actual income is more than the estimated income you reported to the Marketplace when enrolling in your health insurance plan, you may end up owing money to the IRS. This is because you received too much Advance Premium Tax Credit based on the incorrect income amount. Since your Healthcare Cost Assistance benefit covers your net monthly health insurance premium, you may be eligible for additional funds from the Trust to help cover the reimbursement to the IRS. If your reported income had been correct, the Healthcare Cost Assistance benefit would have covered the higher premium amount resulting from a lower amount of Advance Premium Tax Credit.
- If your actual income is less than the estimated income you reported to the Marketplace when enrolling in your health insurance plan, you may end up getting money back from the IRS. This is because you received too little Advance Premium Tax Credit based on the incorrect income amount. The refunded amount from the IRS is the overpayment of Healthcare Cost Assistance benefits that were paid based on your estimated income. Since your Healthcare Cost Assistance benefits cover your net monthly health insurance premium, this refund must be returned to Carewell SEIU 503 for the Healthcare Cost Assistance benefits that were overpaid on your behalf. Please return via check payable to Oregon Homecare Workers Supplemental Trust and mailed to Carewell SEIU 503, Attention: Finance, 1600 Stewart Ave., Suite 700, Westbury, NY 11590 along with a copy of this form and the substantiating documentation.
You will need to include a copy of all of the following forms for a total of 3 forms in order for us to process your request:
- Form 1095A
- Form 8962
- Form 1040 or 1040-SR

Use this form:
- If your actual income is more than the estimated income you reported to the Marketplace when enrolling in your health insurance plan, you may end up owing money to the IRS. This is because you received too much Advance Premium Tax Credit based on the incorrect income amount. Since your Healthcare Cost Assistance benefit covers your net monthly health insurance premium, you may be eligible for additional funds from the Trust to help cover the reimbursement to the IRS. If your reported income had been correct, the Healthcare Cost Assistance benefit would have covered the higher premium amount resulting from a lower amount of Advance Premium Tax Credit.
- If your actual income is less than the estimated income you reported to the Marketplace when enrolling in your health insurance plan, you may end up getting money back from the IRS. This is because you received too little Advance Premium Tax Credit based on the incorrect income amount. The refunded amount from the IRS is the overpayment of Healthcare Cost Assistance benefits that were paid based on your estimated income. Since your Healthcare Cost Assistance benefits cover your net monthly health insurance premium, this refund must be returned to Carewell SEIU 503 for the Healthcare Cost Assistance benefits that were overpaid on your behalf. Please return via check payable to Oregon Homecare Workers Supplemental Trust and mailed to Carewell SEIU 503, Attention: Finance, 1600 Stewart Ave., Suite 700, Westbury, NY 11590 along with a copy of this form and the substantiating documentation.
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Please include a copy of all of the following forms for a total of 3 forms:
- Form 1095A
- Form 8962
- Form 1040 or 1040-SR
Directions on how to upload files

If you DO have the files online:
1. Click on “Browse Files” on this online form
2. Select the file(s) you would like to attach/upload

If you DON’T have the files online:
1. Use your phone to take a photo of any forms and documents that you need to send to us. Make sure to take a complete picture of the form and that your name is included. We can’t read or use blurry photos.
2. Click on “Browse Files” on this online form.
3. Select the file(s) you would like to attach/upload.
Upload Form 1095A *

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Upload Form 8962*

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Upload 1040 or 1040-SR *

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I certify that the information provided on this Advance Premium Tax Credit Adjustment Form and on my attached IRS Forms is true, to the best of my knowledge and belief. I also certify (choose one option below):*

I underestimated my income and owe the IRS money because I received too much of an Advance Premium Tax Credit. I am requesting that Carewell reimburse me for the Advance Premium Tax Credit overpayment I owe the IRS.*I overestimated my income and got money back from the IRS because I received too small an Advance Premium Tax Credit. I acknowledge the money I got back should have gone toward my insurance premium that Carewell paid through Healthcare Cost Assistance benefits. I need to reimburse Carewell for the Healthcare Cost Assistance benefits overpaid for my insurance premium.
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* Please note that Carewell may reimburse you for the Advance Premium Tax Credit overpayment you owe the IRS, but any federal or state taxes you owe the IRS are your responsibility. 
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Upload IRS forms (Form 1095, Form 1040 or 1040-SR, Form 8962)*

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Or Take Photo
If you want to mail or fax documents, forms, and/or checks instead, you can send it to:

Carewell SEIU 503 Address:

Fax: 1-503-765-5543
If you would like to mail or fax any supporting documents to us instead, please send them to:

Mailing Address:

Carewell SEIU 503

Attention: Finance

1600 Stewart Ave., Suite 700

Westbury, NY 11590

Fax Number: 1-503-765-5543

If you are sending a check, please address to:

Carewell SEIU 503
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I certify that the information provided on this Premium Adjustment Reimbursement Form and on my enclosed IRS Forms is true, to the best of my knowledge and belief. I also certify that I have not already received any reimbursement or payment from any other source relating to the premium tax credit overpayment reflected on my enclosed IRS Forms.
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