Instructions For Form 1095-A - Health Insurance Marketplace Statement

If a policy is terminated by an issuer for nonpayment of

Privacy Act and Paperwork Reduction Act Notice.

premiums and advance credit payments are made,

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

enter -0- for a month in which the covered individuals

Internal Revenue laws of the United States. You are

have coverage but the premiums aren't paid (generally,

required by the Internal Revenue Code to give us the

the first month of a grace period). However, if an individual

information. We need it to ensure that taxpayers are

enrolled on the first day of a month terminates coverage

complying with these laws and to allow us to figure and

before the last day of the month, the individual should be

collect the right amount of tax.

considered to have been enrolled for the entire month for

purposes of the applicable SLCSP premium reported in

You aren't required to provide the information

column B.

requested on a form that is subject to the Paperwork

Reduction Act unless the form displays a valid OMB

Column C. Enter the amount of advance credit payments

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

for the month. If more than one Form 1095-A is filed for

instructions must be retained as long as their contents

coverage of a tax filer’s family for the same months, enter

may become material in the administration of any Internal

only the advance credit payment amount allocated to the

Revenue law. Generally, tax returns and return

policy reported on this Form 1095-A. If the tax filer’s family

information are confidential, as required by IRC section

also is enrolled in a stand-alone dental plan, any advance

6103.

credit payments allocated to the stand-alone dental plan

should be added to the advance credit payments

The time needed to complete and file this form will vary

allocated to one of the policies reported on a Form

depending on individual circumstances. The estimated

1095-A.

average time is:

Void Statements

Preparing the form

.3 min.

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

If a Form 1095-A was sent for a policy that shouldn't be

reported on a Form 1095-A, such as a stand-alone dental

plan or a catastrophic health plan, send a duplicate of that

If you have comments concerning the accuracy of

Form 1095-A and check the void box at the top of the

these time estimates or suggestions for making this form

form. Provide this information to the IRS and to the

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

recipient of the statement as soon as possible after

send us comments from IRS.gov/FormComments. Or you

discovering that the statement was sent in error.

can write to the Internal Revenue Service, Tax Forms and

Publications Division, 1111 Constitution Ave. NW,

Correction to Information Reported

IR-6526, Washington, DC 20224. Don't send the form to

Report corrected information on the Form 1095-A to the

this office.

IRS and to the recipient as soon as possible after

discovering that information reported is incorrect. Check

the corrected box on the top of the form.

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Instructions for Form 1095-A (2017)

Instructions For Form 1095-A - Health Insurance Marketplace Statement - 2017 Page 3

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