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STEP

Person 4 (If more than 4 people, this is Person

)

If you have to include more than four people on this application, make a copy of blank information pages for Step 2

Person 4 BEFORE you fill them out. When filling out the additional pages please be sure to tell us how each person is

related to each other person on the application. We need this information to determine eligibility.

Complete Step 2 for each additional person in your household who lives with you and for anyone on your same federal

income tax return if you file one. See page 1 for more information about who to include. If you do not file a tax return,

remember to still add household members who live with you.

1. First name, middle name, last name, and suffix

2. Relationship to Person 1

Relationship to Person 2

Relationship to Person 3

Does this person live with Person 1?

Yes

If no, list address.

3. Date of birth (mm/dd/yyyy)

4. Gender

Male

Female

5. We need a social security number (SSN) for every person applying for health coverage who has one, including those applying

for MassHealth Premium Assistance. An SSN is optional for persons not applying for health coverage, but giving us an SSN

can speed up the application process. We use SSNs to check income and other information to see who is eligible for help with

health coverage costs. If someone needs help getting an SSN, call the Social Security Administration at 1-800-772-1213 (TTY:

1-800-325-0778), or go to socialsecurity.gov. Please see the Member Booklet for more information.

Does this person have a social security number (SSN)?

Yes

If yes, give us the number (optional if not applying)

If no, check one of the following reasons.

Just applied

Noncitizen exception

Religious exception

6. If this person gets an Advance Premium Tax Credit (APTC) for 2017, does this person agree to file a federal tax return for tax

year 2017?

Yes

He or she may not have needed or chosen to file a tax return in the past, but this person will have to file a federal income tax

return for any year that he or she gets an APTC. You must check "Yes" to be eligible for ConnectorCare or APTCs to help pay for

this person's health insurance. This person does NOT need to file a tax return to get MassHealth, CMSP, or HSN, if he or she

qualifies.

If yes, please answer questions a–d. If no, skip to question d.

This person must file a joint federal tax return with a spouse for 2017 to get certain programs unless this person is a victim

of domestic abuse or abandonment. If this person is a victim of domestic abuse or is an abandoned spouse, he or she should

answer "no" to question 6a ("Is this person legally married?") and "no" to question 6b ("Does this person plan to file a joint

federal tax return with a spouse for 2017?"), even if that is not how this person actually files. This person will only need to

include him- or herself and any dependents on this application.

a. Is this person legally married?

Yes

If yes, list name of spouse and date of birth.

b. Does this person plan to file a joint federal tax return with a spouse for 2017?

Yes

c. Will this person claim any dependents on this person's federal income tax return for 2017?

Yes

This person will claim a personal exemption deduction on his or her 2017 federal income tax return for any individual

listed on this application as a dependent who is enrolled in coverage through the Massachusetts Health Connector and

whose premium for coverage is paid in whole or in part by advance payments. If yes, list name(s) and date(s) of birth of

dependents.

d. Will this person be claimed as a dependent on someone else's federal income tax return for 2017?

Yes

If this person is claimed by someone else as a dependent on their 2017 federal income tax return, this may affect this

person's ability to receive a premium tax credit. Do not answer yes to this question if this person is a child under the age of

21 being claimed by a noncustodial parent. If yes, please list the name of the tax filer.

Tax filer date of birth

How is this person related to the tax filer?

Page 14

ACA-3 (Rev. 07/17)

Form Aca-3 - Massachusetts Application For Health And Dental Coverage And Help Paying Costs - Masshealth Form Page 16

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