FEDERAL INCOME TAX IMPLICATONS OF THE ACA MANDATE FOR INDIVIDUAL TAXPAYERS Starting in 2014, the Patient Protection and Affordable Care Act (ACA) mandates that individuals carry minimum essential health insurance coverage (as defined by the federal government). As a result of the ACA mandate, individual taxpayers need to be aware of two possible tax implications when filing their 2014 tax returns. First, taxpayers who fail to comply with the mandate are subject to a penalty that they report on their tax returns. This penalty increases the amount of taxes they will owe, or reduces their tax refund. Second, taxpayers who comply with the mandate by obtaining insurance through the government Marketplace may qualify for a refundable tax credit. This supplement to the 2015 Edition of Essentials for Federal Income Taxation helps explain the tax implications of the new ACA mandate as it applies to the penalty assessed and tax credit available to individual taxpayers in 2014. TAX PENALTY FOR FAILING TO COMPLY Taxpayers who fail to comply with the ACA mandate to carry minimum health insurance coverage face a penalty that they report on their tax returns. The penalty is reported on the line designated, “Health care: individual responsibility” on Form 1040EZ, Form 1040A, or Form 1040. For 2014, the penalty is the greater of (i) $95 for each uninsured adult plus $47.50 for each uninsured child under the age of 18, as reported on the taxpayer’s tax return (up to a maximum of $285), or (ii) 1% of household income over the taxpayer’s filing threshold. EXAMPLE 1 Paul and Jean Hunt (ages 44 and 42, respectively) file a joint return and claim their son as a dependent. The Hunts fail to comply with the ACA mandate for 2014. Their household income is $75,000; their filing threshold is $20,300 (see Figure 1-5, ¶113.02). The Hunts’ penalty for failing to comply with the ACA mandate in 2014 is $547, which is the greater of (i) $237.50 ($95 × 2 adults + $47.50 for 1 child) or (ii) $547 (1% × ($75,000 – $20,300)). PREMIUM TAX CREDIT Taxpayers who comply with the ACA mandate by obtaining their insurance through the government’s health insurance “Marketplace” may be eligible for federal government assistance to subsidize (help pay for) a portion of their premiums. For some taxpayers, this subsidy may be in the form of reduced monthly payments. For others, this assistance comes in the form of a refundable tax credit. 1–2 Essentials of Federal Income Taxation The amount of the premium reduction (advance subsidy) is based on household income and family size reported by the taxpayer at the time of enrollment. Since the taxpayer’s actual household income for the year will likely differ from the self-reported amount provided at the time of enrollment, taxpayers who receive assistance during the year need to reconcile their advanced subsidies (total premium reduction) with the amounts to which they were entitled based on actual household income. Taxpayers whose actual subsidies they received during the year were greater than their entitled assistance must repay the excess by reporting additional tax on their tax returns. Taxpayers who did not receive the assistance they were entitled to during the year claim a refundable tax credit for the difference. Taxpayers Who Qualify for the Premium Tax Credit (PTC) Only taxpayers whose household income is at least 100%, but no more than 400%, of the federal poverty line can claim the refundable premium tax credit (PTC). Taxpayers who qualify for Medicare or Medicaid, or who are eligible to get insurance under an employer-sponsored plan, self-funded student health plan, or through high-risk pools offered by the state government, cannot claim the PTC. Married taxpayers must file a joint tax return in order to claim the PTC; and taxpayers claimed as a dependent on another person’s return are not eligible for this credit. Computing the PTC Using the taxpayer’s total household income and family size, the government determines the maximum amount each taxpayer should have to pay for health insurance. The term the IRS uses to describe this amount is “annual contribution for health care.” The government also determines what the taxpayer’s annual premiums would be for its silver plan (the second lowest cost plan offered by the Marketplace). The taxpayer’s PTC is the lesser of (i) the taxpayer’s actual premiums (prior to any subsidy), or (ii) the difference between the cost of the silver plan and the taxpayer’s annual contribution for health care. Form 1095-A, Health Insurance Marketplace Statement, is an information return sent out to Marketplace participants after the end of each year. This form informs participants of the cost of the premiums (prior to any subsidies) for the policy in which they enrolled, as well as the cost of the premiums for the silver plan, which is the second lowest cost plan the Marketplace offers. A blank Form 1095-A has been included at the end of this supplement. EXAMPLE 2 Duke Smith purchases his insurance through the federal Marketplace. Duke selects a bronze plan, which is the least costly of the four types of plans offered by the Marketplace. Total annual premiums for his plan are $3,000. Had Duke selected the silver plan, his premiums would have been $5,600. Based on Duke’s household income and family size, the government has determined that Duke’s annual contribution for health care is $1,700. Duke’s PTC is $3,000, which is the lesser of (i) $3,000 total premiums for the plan Duke enrolled in, or (ii) $3,900 ($5,600 premiums under the silver plan – $1,700 annual contribution for health care). EXAMPLE 3 Same facts as in Example 2, except that Duke selects a platinum (most expensive) plan, and his premiums are $8,000. Duke’s PTC is $3,900, which is the lesser of (i) $8,000, or (ii) $3,900 ($5,600 – $1,700). Federal Income Tax Implicatons of the ACA Mandate for Individual Taxpayers 1–3 From looking at how the PTC is calculated, the government has concluded that every individual is entitled to receive the benefits offered by the Marketplace’s silver plan. For taxpayers whom the government does not believe have enough household income to pay for these benefits (based on the ratio of household income to the federal poverty line), it is willing to provide assistance up to the difference between the silver plan premiums and the taxpayer’s annual contribution limit (as shown in Example 3). Taxpayers who decide to go with a less expensive (bronze) plan will find their PTC limited to the cost of premiums under that plan (as shown in Example 2). The taxpayer’s annual contribution for health care represents what the government has determined should be the maximum amount that the taxpayer should have to pay for health insurance premiums. It is based on total household income and the number of exemptions the taxpayer claims. Household income is the sum of the taxpayer’s modified AGI and the modified AGI of each of the taxpayer’s dependents. For purposes of the PTC, “modified AGI” is AGI plus any tax-exempt interest income (¶401.06), nontaxable social security benefits (¶307), and foreign earned income exclusion (¶401.02). EXAMPLE 4 Jim and Cathy Thompson live in Missouri. They file a joint tax return and claim their three children as dependents. The Thompsons are not eligible for health insurance through their work, so they purchase their insurance through the Marketplace. On their joint tax return, the Thompsons report $500 of tax-exempt interest income and $52,000 of AGI. The Thompsons’ son earned $2,000 working part-time during the year. The Thompsons’ household income equals $54,500. This amount is the sum of the couples’ $52,500 of modified AGI ($52,000 + $500) and their dependent child’s $2,000 of modified AGI. Once the taxpayer’s household income has been computed, the taxpayer uses an IRS-provided table to find the federal poverty line that corresponds to the total number of (personal and dependency) exemptions the taxpayer claimed. The table that provides poverty lines for most taxpayers is shown below in Table 1. There are separate tables that are used by taxpayers living in Alaska and Hawaii. Each of these tables can be found in the Instructions to Form 8962. Table 1 – Federal Poverty Line for the 48 Contiguous States and the District of Columbia EXAMPLE 5 Total Exemptions Claimed Federal Poverty Line 1 $11,490 2 15,510 3 19,530 4 23,550 5 27,570 6 31,590 7 35,610 8 39,630 Continuing with Example 4, the Thompsons use Table 1 to look up the federal poverty amount for taxpayers claiming five exemptions. This amount is $27,570. The next step in the process of determining the taxpayer’s annual contribution for health care is to divide household income by the federal poverty line. Only taxpayers whose household income falls between 100% and 400% of the federal poverty line qualify for the PTC. EXAMPLE 6 Continuing with Example 5, the Thompsons divide their $54,500 of household income by $27,570 (their federal poverty line). The 1.98 result means that the Thompsons’ household income is 198% above the federal poverty line. Because this percentage falls between 100% and 400%, the Thompsons qualify for the PTC. 1–4 Essentials of Federal Income Taxation Once it has been determine that the taxpayer qualifies for the PTC, the taxpayer’s annual contribution for health care can be computed. This is done by multiplying the taxpayer’s household income by the “applicable figure” from Table 2 (found in the Instructions to Form 8962). The applicable figure is the number in Table 2 that corresponds to the percentage previous calculated (household income divided by the federal poverty line). Table 2 from the instructions to Form 8962 can be found at the end of this supplement. EXAMPLE 7 Continuing with Example 6, the Thompsons go to Table 2 and find that the applicable figure for 198 is .0621. They multiply this number by their $54,500 of household income to arrive at their annual contribution for health care ($54,500 × .0621 = $3,384). This amount represents the maximum amount the government has determined the Thompsons should have to pay for health insurance premiums. After the annual contribution for health care has been computed, taxpayers can use the information reported to them on Form 1095-A to compute their PTC. The taxpayer’s PTC is the lesser of (i) the taxpayer’s actual premiums (prior to any subsidy), or (ii) the difference between the cost of the silver plan and the taxpayer’s annual contribution for health care. EXAMPLE 8 Continuing with Example 7, the Thompsons’ Form 1095-A shows that their annual premiums for the policy they enrolled in was $7,000, and that their premiums would have been $6,600 had they enrolled in the silver plan. The Thompsons’ PTC equals $3,216. This is the lesser of (i) the $7,000 cost of premiums for the plan they enrolled in, or (ii) $3,216 (the $6,600 cost for premiums under the silver plan minus their $3,384 annual contribution for health care). For taxpayers who did not receive any premium reductions during the year, the PTC is reported as a refundable tax credit on Form 1040A (line 45) or Form 1040 (line 69). Form 1040EZ cannot be used to report the PTC. Taxpayers receiving premium reductions (advance payment of PTC) need to reconcile the difference between their advance payment and their PTC. Reconciling Advance Payment of PTC and PTC In addition to providing taxpayers with the cost of their insurance premiums under both the plan they enrolled in and the silver plan, Form 1095-A also provides taxpayers with the amount of premium reductions they received during the year. This amount represents their advance payment of PTC. Taxpayers compare their PTC to their advance payment of PTC. If the taxpayer’s PTC exceeds their advance payment, the difference (“net PTC”) is reported as a refundable tax credit on Form 1040A (line 45) or Form 1040 (line 69). EXAMPLE 9 June and Jim Rosen compute their PTC to be $4,500. The Rosens’ Form 1095-A shows that they received advance payments totaling $3,850 during the year. The Rosens reduce their PTC by their advance payments and report the $650 net PTC ($4,500 – $3,850) as a refundable tax credit on Form 1040A or Form 1040. Excess Advance PTC Repayment When the taxpayer’s advance payment of PTC exceeds their PTC, at least some of the excess must be paid back to the government. This is done by having the taxpayer report an additional tax on Form 1040A (line 29) or Form 1040 (line 46). The amount that must be repaid is the lesser of (i) the excess of the advance payment of PTC over the PTC, or (ii) the amount from Table 3 that corresponds to the taxpayer’s filing status. Thus, the amounts in Table 3 serve as a maximum repayment for taxpayers receiving advanced payments. 1–5 Federal Income Tax Implicatons of the ACA Mandate for Individual Taxpayers Table 3 – Repayment Limitations Taxpayer’s Household Income as a Percentage of Federal Poverty Line: Taxpayer’s Filing Status Single All Others $ 300 $ 600 At least 200% but less than 300% 750 1,500 At least 300% but less than 400% 1,250 2,500 Less than 200% Continuing with Example 8, assume that the Thompsons’ Form 1095-A shows that they received $3,600 of advanced payment of PTC. This amount exceeds the Thompsons’ PTC by $384 ($3,600 – $3,216). From Table 3, the amount that corresponds to MFJ taxpayers whose household income as a percentage of the federal poverty line is 198% is $600. Since the $384 of excess does not exceed this amount, the Thompsons report the $384 as an additional tax on their Form 1040A or Form 1040. EXAMPLE 10 Form 8962 Form 8962, Premium Tax Credit, is a two-page tax form that calculates the taxpayer’s PTC. For taxpayers who received advanced payment of PTC (through reduced premiums), the taxpayer’s net PTC (not enough subsidies) or excess advance PTC repayment (too much subsidy) is also calculated on this form. These calculations are performed in Parts 1-3 of Form 8962 (page 1). Parts 4 and 5 involve complex situations that are beyond the scope of this discussion. In Part 1, taxpayers compute their annual contribution for health care. In Part 2, taxpayers report the information provided to them on Form 1095-A and calculate their PTC. Net PTC is also calculated in Part 2. Taxpayers receiving advanced payment of PTC during the year in excess of their PTC compute their required repayment in Part 3. FILLED-IN FORM 8962 The Thompsons (from Examples 4-8, and Example 10) compute their net PTC or repayment amount by entering on the form the information provided below in bold font. The Thompsons then follow the instructions on Form 8962 to compute their $384 excess advance premium tax credit repayment. They report this amount as an additional tax on Form 1040 (line 46). Line # 1 2a Family size (2 personal + 3 dependency exemptions), 5 Modified AGI reported on the Thompsons’ tax return, $52,500 ($52,000 + $500, provided in Example 4) 2b Modified AGI of the Thompsons’ dependents, $2,000 (provided in Example 4) 4 Federal poverty line, $27,570 (source: Table 1, see Example 5) 6 The Thompsons check Yes. because the 198% reported on line 5 is less than or equal to 400%. 7 Applicable Figure, .0621 (source: Table 2 from the Instructions to Form 8962, see Example 7) 11A Premium Amount, $7,000 (source: Form 1095-A, line 33A. This is the total cost of the premiums (before subsidies) of the insurance plan the Thompsons enrolled in). 11B Annual Premium Amount of SLCSP, $6,600 (source: Form 1095-A, line 33B. This is the total cost of the premiums for the second lowest cost silver plan). 11F Annual Advance Payment of PTC, $3,600 (source: Form 1095-A, line 33C. This is the amount of the Thompsons’ health care premiums that the government paid on their behalf.) 1–6 Essentials of Federal Income Taxation Form 8962 OMB No. 1545-0074 Premium Tax Credit (PTC) Department of the Treasury Internal Revenue Service Name shown on your return a Your social security number James and Cathy Thompson Part 1: Annual and Monthly Contribution Amount Family Size: Enter the number of exemptions from Form 1040 or Form 1040A, line 6d, or Form 1040NR, line 7d . 2a Modified AGI: Enter your modified AGI (see instructions) . . . . . 2a Household Income: Add the amounts on lines 2a and 2b 52,500 . . . b Enter total of your dependents' modified AGI (see instructions) . . . . . . . . . . . . . . . . . . . . 4 Federal Poverty Line: Enter the federal poverty amount as determined by the family size on line 1 and the federal poverty table for your state of residence during the tax year (see instructions). Check the appropriate box for the Alaska b Hawaii c ✔Other 48 states and DC federal poverty table used. a 5 Household Income as a Percentage of Federal Poverty Line: Divide line 3 by line 4. Enter the result rounded to a whole percentage. (For example, for 1.542 enter the result as 154, for 1.549 enter as 155.) (See instructions for special rules.) Is the result entered on line 5 less than or equal to 400%? (See instructions if the result is less than 100%.) 6 ✔ Attachment Sequence No. 73 Relief (see instructions) 859-76-4466 1 3 2014 a Attach to Form 1040, 1040A, or 1040NR. Information about Form 8962 and its separate instructions is at www.irs.gov/form8962. 1 5 2b 3 2,000 54,500 4 27,570 5 198 % 7 .0621 Yes. Continue to line 7. No. You are not eligible to receive PTC. If you received advance payment of PTC, see the instructions for how to report your Excess Advance PTC Repayment amount. 7 Applicable Figure: Using your line 5 percentage, locate your “applicable figure” on the table in the instructions 8a Annual Contribution for Health Care: Multiply line 3 by line 7 . . . . . . 9 Did you share a policy with another taxpayer or get married during the year and want to use the alternative calculation? (see instructions) b Monthly Contribution for Health Care: Divide line 8a by 12. Round to whole dollar amount 3,384 8a 8b Part 2: Premium Tax Credit Claim and Reconciliation of Advance Payment of Premium Tax Credit 282 ✔ No. Continue to line 10. Yes. Skip to Part 4, Shared Policy Allocation, or Part 5, Alternative Calculation for Year of Marriage. Do all Forms 1095-A for your tax household include coverage for January through December with no changes in monthly amounts shown on lines 21–32, columns A and B? ✔ Yes. Continue to line 11. Compute your annual PTC. Skip lines 12–23 No. Continue to lines 12–23. Compute and continue to line 24. your monthly PTC and continue to line 24. 10 Annual Calculation 11 Annual Totals Monthly Calculation A. Premium Amount (Form(s) 1095-A, line 33A) 7,000 B. Annual Premium C. Annual D. Annual Maximum Amount of SLCSP Contribution Amount Premium Assistance (Form(s) 1095-A, line (Line 8a) (Subtract C from B) 33B) 6,600 3,384 3,216 E. Annual Premium F. Annual Advance Payment of PTC Tax Credit Allowed (Form(s) 1095-A, line (Smaller of A or D) 33C) 3,216 3,600 A. Monthly C. Monthly B. Monthly Premium F. Monthly Advance Premium Amount Contribution Amount D. Monthly Maximum E. Monthly Premium Amount of SLCSP Payment of PTC (Form(s) 1095-A, (Amount from line 8b Premium Assistance Tax Credit Allowed (Form(s) 1095-A, lines (Form(s) 1095-A, lines lines 21–32, column or alternative marriage (Subtract C from B) (Smaller of A or D) 21–32, column B) 21–32, column C) A) monthly contribution) 12 13 14 15 16 17 18 January February March April May June July 19 20 21 22 23 August September October November December 24 25 Total Premium Tax Credit: Enter the amount from line 11E or add lines 12E through 23E and enter the total here . Advance Payment of PTC: Enter the amount from line 11F or add lines 12F through 23F and enter the total here . 24 25 26 Net Premium Tax Credit: If line 24 is greater than line 25, subtract line 25 from line 24. Enter the difference here and on Form 1040, line 69; Form 1040A, line 45; or Form 1040NR, line 65. If you elected the alternative calculation for marriage, enter zero. If line 24 equals line 25, enter zero. Stop here. If line 25 is greater than line 24, leave this line blank and continue to line 27 . 26 3,216 3,600 Part 3: Repayment of Excess Advance Payment of the Premium Tax Credit 27 Excess Advance Payment of PTC: If line 25 is greater than line 24, subtract line 24 from line 25. Enter the difference here 27 384 28 Repayment Limitation: Using the percentage on line 5 and your filing status, locate the repayment limitation amount in the instructions. Enter the amount here . . . . . . . . . . . . . . . . . . . 28 600 Excess Advance Premium Tax Credit Repayment: Enter the smaller of line 27 or line 28 here and on Form 1040, line 46; Form 1040A, line 29; or Form 1040NR, line 44 . . . . . . . . . . . . . . . . . . For Paperwork Reduction Act Notice, see your tax return instructions. Cat. No. 37784Z 29 29 384 Form 8962 (2014) 1–7 Federal Income Tax Implicatons of the ACA Mandate for Individual Taxpayers ·¸Â»ʹÆÆÂ¿¹·¸Â»¿½ËÈ» TIP ¼Ê¾»·ÃÅËÄÊÅÄ¿Ļˀ¿É»ÉÉʾ·ÄʼʾʾƑÏÅËÈ·ÆÆÂ¿¹·¸Â»¼¿½ËÈ»¿ÉƔʻʽʻʻƔ¼Ê¾»·ÃÅËÄÊÅÄ¿Ļˀ¿É¸»ÊÍ»»ÄʾʻʻʾÈÅ˽¾ʿʻʻƑÏÅËÈ ·ÆÆÂ¿¹·¸Â»¼¿½ËÈ»¿ÉƔʻ˄ˀʻƔ ÅÈÃʿˀʽʹƑ ¿Ļʼ¿ÉƔƔƔ ÅÄ ÅÈÃʿˀʽʹƑ ¿ĻʾƔƔƔ ÅÈÃʿˀʽʹƑ ¿Ļʼ¿ÉƔƔƔ ÅÄ ÅÈÃʿˀʽʹƑ ¿ĻʾƔƔƔ ÅÈÃʿˀʽʹƑ ¿Ļʼ¿ÉƔƔƔ ÅÄ ÅÈÃʿˀʽʹƑ ¿ĻʾƔƔƔ »ÉÉʾ·Äʸʺʺ ʸʺʺ ʸʺʻ ʸʺʼ ʸʺʽ ʸʺʾ ʸʺʿ ʸʺˀ ʸʻʷ ʸʻʸ ʸʻʹ ʸʻʺ ʸʻʻ ʸʻʼ ʸʻʽ ʸʻʾ ʸʻʿ ʸʻˀ ʸʼʷ ʸʼʸ ʸʼʹ ʸʼʺ ʸʼʻ ʸʼʼ ʸʼʽ ʸʼʾ ʸʼʿ ʸʼˀ ʸʽʷ ʸʽʸ ʸʽʹ ʸʽʺ ʸʽʻ ʸʽʼ ʸʽʽ ʸʽʾ ʸʽʿ ʸʽˀ ʸʾʷ ʸʾʸ ʸʾʹ ʸʾʺ ʸʾʻ ʷƔʷʹʷʷ ʷƔʷʺʷʷ ʷƔʷʺʷʽ ʷƔʷʺʸʹ ʷƔʷʺʸʿ ʷƔʷʺʹʻ ʷƔʷʺʹˀ ʷƔʷʺʺʼ ʷƔʷʺʻʸ ʷƔʷʺʻʾ ʷƔʷʺʼʺ ʷƔʷʺʼˀ ʷƔʷʺʽʼ ʷƔʷʺʾʸ ʷƔʷʺʾʽ ʷƔʷʺʿʹ ʷƔʷʺʿʿ ʷƔʷʺˀʻ ʷƔʷʻʷʷ ʷƔʷʻʷʼ ʷƔʷʻʷˀ ʷƔʷʻʸʻ ʷƔʷʻʸʿ ʷƔʷʻʹʺ ʷƔʷʻʹʿ ʷƔʷʻʺʹ ʷƔʷʻʺʾ ʷƔʷʻʻʸ ʷƔʷʻʻʽ ʷƔʷʻʼʸ ʷƔʷʻʼʼ ʷƔʷʻʽʷ ʷƔʷʻʽʻ ʷƔʷʻʽˀ ʷƔʷʻʾʻ ʷƔʷʻʾʿ ʷƔʷʻʿʺ ʷƔʷʻʿʾ ʷƔʷʻˀʹ ʷƔʷʻˀʾ ʷƔʷʼʷʸ ʷƔʷʼʷʽ ʷƔʷʼʸʷ ʸʾʼ ʸʾʽ ʸʾʾ ʸʾʿ ʸʾˀ ʸʿʷ ʸʿʸ ʸʿʹ ʸʿʺ ʸʿʻ ʸʿʼ ʸʿʽ ʸʿʾ ʸʿʿ ʸʿˀ ʸˀʷ ʸˀʸ ʸˀʹ ʸˀʺ ʸˀʻ ʸˀʼ ʸˀʽ ʸˀʾ ʸˀʿ ʸˀˀ ʹʷʷ ʹʷʸ ʹʷʹ ʹʷʺ ʹʷʻ ʹʷʼ ʹʷʽ ʹʷʾ ʹʷʿ ʹʷˀ ʹʸʷ ʹʸʸ ʹʸʹ ʹʸʺ ʹʸʻ ʹʸʼ ʹʸʽ ʹʸʾ ʷƔʷʼʸʼ ʷƔʷʼʹʷ ʷƔʷʼʹʻ ʷƔʷʼʹˀ ʷƔʷʼʺʺ ʷƔʷʼʺʿ ʷƔʷʼʻʺ ʷƔʷʼʻʾ ʷƔʷʼʼʹ ʷƔʷʼʼʽ ʷƔʷʼʽʸ ʷƔʷʼʽʽ ʷƔʷʼʾʷ ʷƔʷʼʾʼ ʷƔʷʼʾˀ ʷƔʷʼʿʻ ʷƔʷʼʿˀ ʷƔʷʼˀʺ ʷƔʷʼˀʿ ʷƔʷʽʷʹ ʷƔʷʽʷʾ ʷƔʷʽʸʹ ʷƔʷʽʸʽ ʷƔʷʽʹʸ ʷƔʷʽʹʼ ʷƔʷʽʺʷ ʷƔʷʽʺʻ ʷƔʷʽʺʾ ʷƔʷʽʻʸ ʷƔʷʽʻʻ ʷƔʷʽʻʿ ʷƔʷʽʼʸ ʷƔʷʽʼʼ ʷƔʷʽʼʿ ʷƔʷʽʽʹ ʷƔʷʽʽʼ ʷƔʷʽʽˀ ʷƔʷʽʾʹ ʷƔʷʽʾʽ ʷƔʷʽʾˀ ʷƔʷʽʿʺ ʷƔʷʽʿʽ ʷƔʷʽˀʷ ʹʸʿ ʹʸˀ ʹʹʷ ʹʹʸ ʹʹʹ ʹʹʺ ʹʹʻ ʹʹʼ ʹʹʽ ʹʹʾ ʹʹʿ ʹʹˀ ʹʺʷ ʹʺʸ ʹʺʹ ʹʺʺ ʹʺʻ ʹʺʼ ʹʺʽ ʹʺʾ ʹʺʿ ʹʺˀ ʹʻʷ ʹʻʸ ʹʻʹ ʹʻʺ ʹʻʻ ʹʻʼ ʹʻʽ ʹʻʾ ʹʻʿ ʹʻˀ ʹʼʷ ʹʼʸ ʹʼʹ ʹʼʺ ʹʼʻ ʹʼʼ ʹʼʽ ʹʼʾ ʹʼʿ ʹʼˀ ʹʽʷ ʷƔʷʽˀʺ ʷƔʷʽˀʾ ʷƔʷʾʷʷ ʷƔʷʾʷʻ ʷƔʷʾʷʾ ʷƔʷʾʸʸ ʷƔʷʾʸʻ ʷƔʷʾʸʿ ʷƔʷʾʹʸ ʷƔʷʾʹʼ ʷƔʷʾʹʿ ʷƔʷʾʺʹ ʷƔʷʾʺʼ ʷƔʷʾʺˀ ʷƔʷʾʻʹ ʷƔʷʾʻʽ ʷƔʷʾʻˀ ʷƔʷʾʼʺ ʷƔʷʾʼʽ ʷƔʷʾʽʷ ʷƔʷʾʽʺ ʷƔʷʾʽʾ ʷƔʷʾʾʷ ʷƔʷʾʾʻ ʷƔʷʾʾʾ ʷƔʷʾʿʸ ʷƔʷʾʿʻ ʷƔʷʾʿʿ ʷƔʷʾˀʸ ʷƔʷʾˀʼ ʷƔʷʾˀʿ ʷƔʷʿʷʹ ʷƔʷʿʷʼ ʷƔʷʿʷʿ ʷƔʷʿʸʸ ʷƔʷʿʸʻ ʷƔʷʿʸʾ ʷƔʷʿʹʷ ʷƔʷʿʹʹ ʷƔʷʿʹʼ ʷƔʷʿʹʿ ʷƔʷʿʺʸ ʷƔʷʿʺʻ ÅÈÃʿˀʽʹƑ ¿Ļʼ¿ÉƔƔƔ ÅÄ ÅÈÃʿˀʽʹƑ ¿ĻʾƔƔƔ ʹʽʸ ʹʽʹ ʹʽʺ ʹʽʻ ʹʽʼ ʹʽʽ ʹʽʾ ʹʽʿ ʹʽˀ ʹʾʷ ʹʾʸ ʹʾʹ ʹʾʺ ʹʾʻ ʹʾʼ ʹʾʽ ʹʾʾ ʹʾʿ ʹʾˀ ʹʿʷ ʹʿʸ ʹʿʹ ʹʿʺ ʹʿʻ ʹʿʼ ʹʿʽ ʹʿʾ ʹʿʿ ʹʿˀ ʹˀʷ ʹˀʸ ʹˀʹ ʹˀʺ ʹˀʻ ʹˀʼ ʹˀʽ ʹˀʾ ʹˀʿ ʹˀˀ ʺʷʷʾÈËʻʷʷ ʷƔʷʿʺʾ ʷƔʷʿʻʷ ʷƔʷʿʻʺ ʷƔʷʿʻʽ ʷƔʷʿʻˀ ʷƔʷʿʼʸ ʷƔʷʿʼʻ ʷƔʷʿʼʾ ʷƔʷʿʽʷ ʷƔʷʿʽʺ ʷƔʷʿʽʽ ʷƔʷʿʽˀ ʷƔʷʿʾʹ ʷƔʷʿʾʼ ʷƔʷʿʾʿ ʷƔʷʿʿʷ ʷƔʷʿʿʺ ʷƔʷʿʿʽ ʷƔʷʿʿˀ ʷƔʷʿˀʹ ʷƔʷʿˀʼ ʷƔʷʿˀʿ ʷƔʷˀʷʸ ʷƔʷˀʷʻ ʷƔʷˀʷʾ ʷƔʷˀʷˀ ʷƔʷˀʸʹ ʷƔʷˀʸʼ ʷƔʷˀʸʿ ʷƔʷˀʹʸ ʷƔʷˀʹʻ ʷƔʷˀʹʾ ʷƔʷˀʺʷ ʷƔʷˀʺʺ ʷƔʷˀʺʽ ʷƔʷˀʺʿ ʷƔʷˀʻʸ ʷƔʷˀʻʻ ʷƔʷˀʻʾ ʷƔʷˀʼʷ 1–8 Form Essentials of Federal Income Taxation 1095-A Department of the Treasury Internal Revenue Service Part I Health Insurance Marketplace Statement a Information about Form 1095-A and its separate instructions is at www.irs.gov/form1095a. OMB No. 1545-2232 CORRECTED 2014 Recipient Information 1 Marketplace identifier 2 Marketplace-assigned policy number 3 Policy issuer's name DRAFT AS OF October 1, 2014 DO NOT FILE 4 Recipient's name 5 Recipient's SSN 6 Recipient's date of birth 7 Recipient's spouse's name 8 Recipient's spouse's SSN 9 Recipient's spouse's date of birth 10 Policy start date 11 Policy termination date 12 Street address (including apartment no.) 13 City or town 14 State or province 15 Country and ZIP or foreign postal code Part II Coverage Household A. Covered Individual Name 16 B. Covered Individual SSN C. Covered Individual Date of Birth D. Covered Individual Start Date E. Covered Individual Termination Date 17 18 19 20 Part III Household Information Month A. Monthly Premium Amount B. Monthly Premium Amount of Second Lowest Cost Silver Plan (SLCSP) C. Monthly Advance Payment of Premium Tax Credit 21 January 22 February 23 March 24 April 25 May 26 June 27 July 28 August 29 September 30 October 31 November 32 December 33 Annual Totals For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. Cat. No. 60703Q Form 1095-A (2014)
© Copyright 2026 Paperzz