July 14, 2020
Attn: Internal Revenue Service
Your Name:
Your Address:
Taxpayer’s SSN:
Spouse SSN:
Phone:
Tax Year 2016 – Form 1040
This letter is our formal written Protective Claim for Refund of Additional Medicare Tax and/or Net Investment Income Tax liabilities paid for tax year 2016. These taxes are contingent on the pending Supreme Court case California, et al., Petitioners vs. Texas, et al. No. 19-840 (U.S. Supreme Court).
These taxes were assessed and timely paid with my (our) individual income tax return Form 1040, under provisions of the Patient Protection and Affordable Care Act (ACA) of 2010.
- Additional Medicare Tax of .9% was assessed in total on Form 8959, Part IV, Line 18 for $ XXX.XX
- Net Investment Income Tax was assessed in total on Form 8960, Part III, Line 17 for $ XXX.XX
Upon favorable decision of this case, I am (we are) requesting a full refund of these assessed taxes and interest, as provided by law, on the principal amount of the tax overpayment.
Please contact me (us) if you need any additional information to process this claim.
Thank you.
Sincerely,
______________________
Taxpayer’s signature
______________________
Spouse’s signature
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