14765

Employee Premium Tax Credit (PTC) Listing

Agency
IRS
Revision
Rev. 5-2021
Fillable fields
293
Pages
1
Official source
IRS form page
Checked
October 21, 2026
Fill 14765 online
Page 1 of form 14765

Form 14765: Employee Premium Tax Credit (PTC) Listing

Form 14765, Employee Premium Tax Credit (PTC) Listing, is a one-page Internal Revenue Service listing tied to an employer. Its header holds the employer name, employer ID number and tax year, and each row names an employee who received a premium tax credit, with the months involved.

The form is written to the employer. The paragraph at the top says that any month not highlighted is a month the employee received a PTC and no safe harbor or other relief from the ESRP was applicable, and that the employee is an assessable full-time employee for that month. A month showing XF, XG or XH reflects a determination that the safe harbor claimed (2F, 2G or 2H) does not qualify.

The form carries no line instructions beyond that paragraph. You can fill out Form 14765 free in your browser on this page and download the result without an account.

What's on Form 14765

Header

Employer name, employer ID number and tax year.

Employee name and SSN

The employee's name, last name first, and the last 4 digits of the Social Security number.

All 12 months indicator codes

Indicator codes from Form 1095-C, lines 14 and 16 combined, that apply to all 12 months.

Monthly columns

One column for each month from January through December. Highlighting and the codes XF, XG or XH mark the outcome for each month.

Additional Information Attached

The last column marks rows for which more information is attached.

How to read and fill out Form 14765

  1. 1

    Check the header

    Confirm the employer name, employer ID number and tax year at the top of the listing.

  2. 2

    Find each employee

    Each row gives the employee's name, last name first, and the last 4 digits of the SSN.

  3. 3

    Read the indicator codes

    The all 12 months column shows the codes from Form 1095-C, lines 14 and 16 combined.

  4. 4

    Read each month

    The form says a month not highlighted is a month the employee received a PTC and no safe harbor or other relief from the ESRP applied, so the employee is an assessable full-time employee for that month.

  5. 5

    Look for XF, XG or XH

    These codes mean the safe harbor claimed with code 2F, 2G or 2H was determined not to qualify for that month.

  6. 6

    Attach your computation

    If the safe harbor still seems to apply, the form says a computation may go with a written request for reconsideration. Mark the Additional Information Attached column for that row.

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Where it goes and what the form says

No address or deadline printed

The form prints no mailing address, fax number or deadline. It refers only to a written request for reconsideration.

Reconsideration

The form says: "If you still think the safe harbor applies, you may provide your computation with your written request for reconsideration."

Codes come from Form 1095-C

The indicator codes column draws on Form 1095-C, lines 14 and 16 combined. The safe harbor codes named on the form are 2F, 2G and 2H.

Privacy on the listing

The listing shows only the last 4 digits of each employee's Social Security number.

Related forms

Who deals with Form 14765?

  • Employers named in the header

    The header names the employer, its employer ID number and the tax year the listing covers.

  • Employees listed by month

    Each row lists an employee by last name and first name and the last 4 digits of the Social Security number, with a column for each month.

  • Employers that claimed a safe harbor

    A month showing XF, XG or XH means the safe harbor claimed with code 2F, 2G or 2H was determined not to qualify.

  • Employers asking for reconsideration

    The form says that if you still think the safe harbor applies, you may provide your computation with your written request for reconsideration.

The form does not say who fills it in. Its heading is Department of the Treasury, Internal Revenue Service, and its wording addresses the employer as "you" when it refers to a determination about a safe harbor.

Official sources and the blank

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Questions about Form 14765

What is Form 14765?

It is the Employee Premium Tax Credit (PTC) Listing, an IRS listing for one employer and tax year that shows, month by month, employees who received a premium tax credit.

What does an unhighlighted month mean?

The form says any month not highlighted is a month the employee received a PTC and no safe harbor or other relief from the ESRP was applicable. The employee is an assessable full-time employee for that month.

What do XF, XG and XH mean?

The form says a month showing XF, XG or XH is due to a determination that the employer does not qualify for the safe harbor being claimed, 2F, 2G or 2H.

Can the employer disagree with the listing?

The form says that if you still think the safe harbor applies, you may provide your computation with your written request for reconsideration.

Are there separate instructions for Form 14765?

No separate instructions are linked for this form. The only guidance is the paragraph printed at the top of the listing.