Obamacare Health Insurance Interview
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2ACA / OBAMACARE HEALTH INSURANCE INTERVIEW
Taxpayer Information (completed by the Tax Advisor)
Taxpayer Name
SSN or ITIN ___ ___ ___ - ___ ___ - ___ ___ ___ ___
Spouse Name
SSN or ITIN ___ ___ ___ - ___ ___ - ___ ___ ___ ___
1. Did you receive an IRS form (__)1095-A (__)1095-B (__)1095-C (__) None
2. Did you have the same Health Insurance for yourself, spouse and all the dependents you are claiming on your tax
return for all 12 months of 2014?
□ YES □ NO (__) n/a
If NO, skip to box #4
3. If you checked YES in box #2, (you had Health Insurance for everyone for all 12 months)
□ YES □ NO (__) n/a
Was your Insurance provided by your employer?
□ YES □ NO (__) n/a
Did you purchase Insurance directly from an Agent (not through the Marketplace)
If YES
Who was your Agent? Name ______________& Phone (____) ____ - ______
□ YES □ NO (__) n/a
Did you purchase your Insurance through the Marketplace (Healthcare.gov)
If YES
Insurance Company ______________& Monthly Premium Paid $_____/mo
□ YES □ NO (__) n/a
Were you covered by Medicare or Medicaid?
4. If you checked NO in box #2, (you did not have Health Insurance for everyone for all 12 months)
Did anyone have any Health Insurance Coverage for any part of the year?
□ YES □ NO (__) n/a
If YES: What months did they have Health Coverage? (chart below)
If covered for full year, check "full year" box; If no coverage, leave colums blank after that person's name.
Rec'd
Full
Name
Coverage Type(s)*
Subsidy
Year Jan Feb Mar Apr May Jun Jul
Aug Sep Oct Nov Dec
1
2
3
4
5
6
7
8
*Acceptable Coverage Types:
•
Employer Sponsored Group Plan (EMP) • Medicaare (Mcare) • Medicaid (Mcaid)
• Government plan for federal and/or state employees (GOV) • Military and/or veterans medical coverage (Mil)
• Individual qualified plans (Ind) • Children's Health Insurance Program/MiChild (CHIP) • Peace Corps health plan (PC)
• Marketplace Health Plan purchased through "Healthcare.gov" exchange (Exch)
5. If you checked NO in Box #4 (no one had any health coverage for 2014)
Did you file for an Exemption with Health & Human Services?
□ YES □ NO (__) n/a
□ YES □ NO (__) n/a
Do you meet any of the following criteria for penalty exemption? (see reverse)
Taxpayer Statement:
Under penalties of perjury, I declare that I have examined this election, including accompanying documents, and, to the best of my
knowledge and belief, the election contains all the relevant facts relating to the election, and such facts are true, correct, and complete.
Signatures: Taxpayer ____________________________ Spouse: ______________________________
v.01/09/2015
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