Affordable Care Act Obamacare Page 2
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2ACA 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: ________________________
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Parent category: Medical