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Person 1 (continued)

STEP 2

DEDUCTIONS

31. Check all that apply. Give the amount and how often you get it.

If you pay for certain things that can be deducted on a federal income tax return, telling us about them could make the cost of

health coverage a little lower. NOTE: Do not include a cost already considered in the answers to net self-employment income,

net rental, or net farming or fishing income. Enter the amount up to the maximum deduction allowed by the IRS.

Alimony paid $

How often?

Student loan interest $

How often?

Other tax deductions (educator expenses; certain business expenses of reservists, performing artists, or fee-based

government officials; health savings account deduction; moving expenses related to a job change; deductible part of self-

employment tax; contribution to self-employed SEP, SIMPLE, and qualified plans; self-employed health insurance deduction;

penalty on early withdrawal of savings; Individual Retirement Account (IRA) deduction; higher education tuition and fees;

and domestic production activities deduction). Do not include any type of deduction that is not listed above.

Type

How often?

YEARLY INCOME

32. What is your total expected income for the current calendar year?

33. What is your total expected income for next calendar year, if different?

THANKS! This is all we need to know about you. Go to Step 2 Person 2 to add another household member, if needed.

Otherwise, go to Step 3 American Indian or Alaska Native (AI/AN) Household Member(s).

STEP

Person 2

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 2 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

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.

Page 6

ACA-3 (Rev. 07/17)

Form Aca-3 - Massachusetts Application For Health And Dental Coverage And Help Paying Costs - Masshealth Form Page 8

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