Instructions For Form 1095-A - Health Insurance Marketplace Statement

Part II—Coverage Household

enter the premiums for the SLCSP that would apply to all

individuals identified in Part II as covered for the month.

Enter on lines 16 through 20 and columns A through E

Leave column B blank if no advance credit payments are

information for each individual including the recipient and

made for the coverage and your state has provided a tool

the recipient's spouse covered under the policy. If

for determining the applicable SLCSP for the year of

advance credit payments were made for the coverage on

coverage at the time of filing the tax return.

a recipient’s behalf enter in Part II information only for

covered individuals for whom the recipient attested to the

Column C. Enter the amount of advance credit payments

Marketplace at enrollment the intention to claim a

for the month.

personal exemption deduction on the tax return (recipient,

Correction to Information Reported

spouse, and dependents). If advance credit payments

were not made on behalf of a recipient enter in Part II

Report corrected information on the Form 1095-A to the

information for all covered individuals.

IRS and to the recipient as soon as possible after

discovering that information reported is incorrect. Check

For each line, enter a date of birth in column C only if

the corrected box on the top of the form.

column B is blank. Enter in column D the date the

coverage started for the individual. Enter in column E the

Privacy Act and Paperwork Reduction Act Notice.

date of termination if the individual's coverage was

We ask for the information on this form to carry out the

terminated during the year. If the coverage was in effect at

Internal Revenue laws of the United States. You are

the end of the year, enter 12/31/2014.

required by the Internal Revenue Code to give us the

If there are more than 5 covered individuals,

information. We need it to ensure that you are complying

complete one or more additional Forms 1095-A,

with these laws and to allow us to figure and collect the

TIP

Part II.

right amount of tax.

You are not required to provide the information

Part III—Household Information

requested on a form that is subject to the Paperwork

Enter information in Part III, lines 21 through 32, for each

Reduction Act unless the form displays a valid OMB

month of coverage. This information is determined on a

control number. Books or records relating to a form or its

Draft as of

monthly basis and may change during the year if there is a

instructions must be retained as long as their contents

change in enrollment or other circumstances that affect

may become material in the administration of any internal

eligibility for the premium tax credit. Total the amounts on

revenue law. Generally, tax returns and return information

lines 21 through 32 and enter on line 33.

are confidential, as required by section 6103.

Column A. Enter the total monthly premiums for the

The time needed to complete and file this form will vary

policy in which the recipient or family members enrolled.

depending on individual circumstances. The estimated

Include only the premiums allocable to essential health

average time is:

08/28/2014

benefits. However, include the premiums for a

stand-alone dental plan allocable to pediatric dental

Recordkeeping

. . . . . . . . . . . . . . . .

coverage in the total monthly premium. If more than one

Form 1095-A is filed for coverage of the recipient’s family

Learning about the law or the

for the same months, include the premium for pediatric

form

. . . . . . . . . . . . . . . . . . . . . . . .

dental coverage in the amount in column A on only one

Preparing the form

. . . . . . . . . . . .

Form 1095-A.

Copying, assembling, and

Column B. Enter the premiums for the applicable second

sending the form to the IRS

. . . . . .

lowest cost silver plan (SLCSP) used as a benchmark to

compute monthly advance credit payments. The

applicable SLCSP is the SLCSP that would cover only

If you have comments concerning the accuracy of

individuals identified in Part II covered during the month

these time estimates or suggestions for making this form

who were identified at enrollment as members of the

simpler, we would be happy to hear from you. You can

recipient’s family (the individuals who would be claimed

write to the Internal Revenue Service; Tax Forms and

as personal exemption deductions on the recipient’s tax

Publications Division; SE:W:CAR:MP:T, 1111 Constitution

return) and who are not eligible for other health coverage.

Ave. NW, IR-6526, Washington, DC 20224. Do not send

See Publication 974, Premium Tax Credit, for additional

the form to this office. Instead, see Where To File, earlier.

information on eligibility for other health coverage. If no

advance credit payments are made for the coverage,

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Instructions for Form 1095-A 2014

Instructions For Form 1095-A - Health Insurance Marketplace Statement - 2014 Page 3

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