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Person 1 (continued)

STEP 2

You may not have needed or chosen to file a tax return in the past, but you will have to file a federal income tax return for

any year that you get an APTC. You must check "Yes" to be eligible for ConnectorCare or APTCs to help pay for your health

insurance. You do NOT need to file a tax return to get MassHealth, CMSP, or HSN, if you qualify.

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

You must file a joint federal tax return with your spouse for 2017 to get certain programs unless you are a victim of domestic

abuse or abandonment. If you are a victim of domestic abuse or are an abandoned spouse, you should answer "no" to question

6a ("Are you legally married?") and "no" to question 6b ("Do you plan to file a joint federal tax return with your spouse for

2017?"), even if that is not how you actually file. You will only need to include yourself and any dependents on this application.

a. Are you legally married?

Yes

No See IRS Publication 501 or consult a tax professional for tax filing information.

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

b. Do you plan to file a joint federal tax return with your spouse for 2017?

Yes

c. Will you claim any dependents on your federal income tax return for 2017?

Yes

You will claim a personal exemption deduction on your 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 you be claimed as a dependent on someone else's federal income tax return for 2017?

Yes

No.

If you are claimed by someone else as a dependent on their 2017 federal income tax return, this may affect your ability to

receive a premium tax credit. Do not answer yes to this question if you are 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 are you related to the tax filer?

Is the tax filer married, filing a joint return?

Yes

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

Who else does the tax filer claim as dependents?

To complete this section, read the following statement. Then check yes below the statement if:

1. You have received an APTC or ConnectorCare in the past, and

2. The statement is true for all people listed in the household.

Statement

I filed a federal income tax return with the Internal Revenue Service (IRS) for every year that I received an Advance Premium

Tax Credit (APTC). When I filed, I included IRS Form 8962, which had information about the tax credit I received, so the IRS

could reconcile my APTC.

Yes

7. Are you applying for health or dental coverage for YOURSELF?

Yes

(Even if you have coverage, there might be a program with better coverage or lower costs. )

If yes, answer all the questions below. If no, answer Questions 14 and 15, then go to

Income Information

on page 4.

8. Are you a U.S. citizen or U.S. national?

Yes

If yes, are you a naturalized citizen (not born in the U.S.)?

Yes

Alien number

Naturalization or citizenship certificate number

9. If you are a noncitizen, do you have an eligible immigration status?

Yes

See page 22, “Immigration Statuses and Document Types” for help. If no or no response, you may get only one or more of the

following: MassHealth Standard (if pregnant), MassHealth Limited, the Children’s Medical Security Plan (CMSP), or the Health

Safety Net (HSN). Go to Question 10.

a. If yes, do you have an immigration document?

Yes

It may help us to process this application faster if you include a copy of your immigration document with the application.

We will try to verify your immigration status through an electronic data match. Please list all the immigration statuses or

conditions that have applied to you since you entered the U.S. If you need more space, attach another sheet of paper.

Status award date (mm/dd/yyyy)

(For battered persons, enter the date the petition was approved as

properly filed.)

Page 3

ACA-3 (Rev. 07/17)

Form Aca-3 - Massachusetts Application For Health And Dental Coverage And Help Paying Costs - Masshealth Form Page 5

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