13441: Fill out & sign online

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Click ‘Get Form’ to open it in the editor.
Begin by entering your Social Security Number at the top of the form. This is essential for identification.
In Part 1, provide your general information including your name, date of birth, and contact details. Ensure accuracy as this information is crucial for processing.
Move to Part 2 and check the appropriate box that certifies your eligibility for the HCTC. Review each statement carefully before confirming.
In Part 3, list any family members you are registering. Include their names, relationships, and Social Security Numbers. Make sure to indicate if they are on your health plan.
Complete Part 4 with detailed health plan information. This includes provider name, effective coverage date, and premium amounts. If applicable, ensure you note any changes in coverage.
Finally, review all sections for completeness and accuracy before signing in Part 6. Your signature confirms that all provided information is true.

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