AFFORDABLE CARE ACT (Obamacare)
The following worksheet must be completed for each person on your tax return as well as anyone else that is covered under your
health insurance plan. Make copies as needed, or contact our office for addition copies of this worksheet. You can also find this
form on our website
to complete the proper forms on your 2014 tax return.
ACA Worksheet:
Name: _________________________________________
If not on current tax return, please provide SS# and Date of Birth for this person. ________________________________________
Please indicate for each month what type of health insurance coverage this person was covered under:
Jan Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct Nov
Dec
Employer/Group Plan
Marketplace (Healthcare.gov)
*Provide form 1095‐A from Marketplace
Medicaid/Medicare/CHIP/VA
COBRA
Exempt
*Provide certificate from Marketplace
Unknown
ACA Worksheet:
Name: _________________________________________
If not on current tax return, please provide SS# and Date of Birth for this person. ________________________________________
Please indicate for each month what type of health insurance coverage this person was covered under:
Jan Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct Nov
Dec
Employer/Group Plan
Marketplace (Healthcare.gov)
*Provide form 1095‐A from Marketplace
Medicaid/Medicare/CHIP/VA
COBRA
Exempt
*Provide certificate from Marketplace
Unknown
I, the taxpayer, certify that the information contained on this page is true and accurate to the best of my knowledge.
Signature: _____________________________________________ Date: ________________________
(add’l sheets on back)