Instructions for Returning Funds
Bullets at the top: the form covers the Government's portion only, the insured's SSN is entered as the last four digits, and the form accompanies all returned funds.
13560
Health Plan Administrator (HPA) Return of Funds
- Agency
- IRS
- Revision
- Rev. 5-2017
- Fillable fields
- 6
- Pages
- 1
- Official source
- IRS form page
- Checked
- October 21, 2026
Form 13560: Health Plan Administrator (HPA) Return of Funds
Form 13560, Health Plan Administrator (HPA) Return of Funds, is the form a health plan administrator completes when it sends money back to the HCTC Program. The form says it is for returning the Government's portion of the insurance premium only, and that the participant's portion is returned directly to the participant.
The form says it MUST accompany all returned funds, in order to ensure proper handling. An organization that uses a similar form providing ALL of the requested information may submit that internal document in lieu of this form. One Form 13560 is used per insured.
Form 13560 is an administrator's form, not an individual tax return. You can fill it out free in your browser on this page and download the result without an account.
What's on Form 13560
Three ways to return funds
Send an HPA check, reverse an EFT transaction through the bank, or return an uncashed US Treasury check. Each option says where the form goes.
Funds for several people
Either a separate check and form (or internal document) for each individual, or one bulk check with a detailed list showing how the payment is allocated.
Insured Name and SSN
The insured's name and the last 4 digits of the insured's Social Security number. The form says to use one form per insured.
Coverage end and reason
Date Coverage Ended and Reason for Termination for the insured's coverage.
Amount and reason returned
Total Amount Returned and Reason for Returned Funds close out the form.
How to fill out Form 13560
- 1
Choose the return method
Pick one option: an HPA check made payable to US Treasury - HCTC, a reversal of an EFT transaction, or return of an uncashed US Treasury check.
- 2
Insured Name and SSN
Enter the insured's name and only the last four digits of the insured's Social Security number.
- 3
Coverage end and termination
Enter the Date Coverage Ended and the Reason for Termination.
- 4
Amount and reason
Enter the Total Amount Returned and the Reason for Returned Funds. Mark N/A on any line that does not apply.
- 5
More than one participant
The form asks for a detail listing of all participants: Insured Names, last 4 digits of SSN, Participant's PIN, Date Coverage Ended, Reason for termination, total amount returned and reason for returned funds.
- 6
Send it
Attach the check and mail the form, or fax it after asking the bank to reverse the EFT back to the US Department of Treasury.
The form asks to complete all sections and to mark N/A wherever applicable.
Why fill Form 13560 on indox
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
- Fill the form right in your browser, no software to install
- Free to fill and free to download, with no account
- The official blank straight from the IRS, not a copy someone retyped
- Works on a phone, tablet or computer
Where it goes and what to include
Mailing a check
Make the check payable to US Treasury - HCTC, attach it to the form and mail to Internal Revenue Service, Beckley Finance Center PO Box 9002, Beckley WV 25802-9002.
Reversing an EFT
Notify the bank to reject the EFT and reverse it back to the US Department of Treasury, then fax the form to Internal Revenue Service - HCTC, FAX #: 855-780-9044.
Uncashed Treasury check
Attach the uncashed US Treasury check to the completed form and mail it to the same Beckley Finance Center address.
Participant's portion
The form says the participant's portion must be returned directly to the participant. Only the Government's portion comes back with this form.
Time to complete
The form says the estimated average time to complete it is 15 minutes. The form prints no due date.
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ACH Vendor/Miscellaneous Payment Enrollment - HCTC
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13441-A
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13973
Health Coverage Tax Credit (HCTC) Blank Payment Coupon
23 fields, 1 page
14095
The Health Coverage Tax Credit (HCTC) Reimbursement Request
26 fields, 2 pages
1099-H
Health Coverage Tax Credit (HCTC) Advance Payments
45 fields, 3 pages
8885
Health Coverage Tax Credit
18 fields, 1 page
Who fills out Form 13560?
The form is written for health plan administrators. It goes to the IRS with the returned funds.
Official sources and the blank
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Questions about Form 13560
Who fills out Form 13560?
A health plan administrator (HPA) that is returning the Government's portion of an insurance premium to the HCTC Program.
Does Form 13560 return the participant's share?
No. The form says it is for the Government's portion only and that the participant's portion must be returned directly to the participant.
Can an administrator use its own form instead?
Yes. The form says an internal document is acceptable in lieu of Form 13560 if it provides ALL of the information the form requests.
How are funds for several people returned?
The form gives two options: a separate check and form for each individual, or one bulk check with a detailed list showing how the payment is allocated.
How much of the Social Security number goes on the form?
Only the last four digits of the insured's Social Security number.
Where is Form 13560 sent?
With a check, by mail to the IRS Beckley Finance Center PO Box 9002, Beckley WV 25802-9002. For an EFT reversal, by fax to 855-780-9044.