Form 8965, Health Coverage Exemptions
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18965
OMB No. 1545-0074
Health Coverage Exemptions
2015
Form
Attach to Form 1040, Form 1040A, or Form 1040EZ.
▶
Department of the Treasury
Attachment
Information about Form 8965 and its separate instructions is at
75
▶
Internal Revenue Service
Sequence No.
Name as shown on return
Your social security number
Complete this form if you have a Marketplace-granted coverage exemption or you are claiming a coverage exemption
on your return.
Marketplace-Granted Coverage Exemptions for Individuals. If you and/or a member of your tax household
Part I
have an exemption granted by the Marketplace, complete Part I.
(a)
(b)
(c)
Name of Individual
SSN
Exemption Certificate Number
1
2
3
4
5
6
Part II
Coverage Exemptions Claimed on Your Return for Your Household
Are you claiming an exemption because your household income is below the filing threshold? .
.
.
.
.
.
7a
Yes
No
b
Are you claiming a hardship exemption because your gross income is below the filing threshold?
.
.
.
.
Yes
No
Coverage Exemptions Claimed on Your Return for Individuals. If you and/or a member of your tax
Part III
household are claiming an exemption on your return, complete Part III.
(c)
(d)
(a)
(b)
(e)
(f)
(g)
(h)
(i)
(j)
(k)
(l)
(m)
(n)
(o)
(p)
Exemption
Full
Name of Individual
SSN
Jan
Feb
Mar
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
Type
Year
8
9
10
11
12
13
8965
For Privacy Act and Paperwork Reduction Act Notice, see your tax return instructions.
Form
(2015)
Cat. No. 37787G
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