Form 1095-A - Health Insurance Marketplace Statement Page 2
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31095-A
Health Insurance Marketplace Statement
VOID
OMB No. 1545-2232
Form
2017
Do not attach to your tax return. Keep for your records.
CORRECTED
▶
Department of the Treasury
Go to for instructions and the latest information.
Internal Revenue Service
▶
Recipient Information
Part I
1 Marketplace identifier
2 Marketplace-assigned policy number
3 Policy issuer’s name
4 Recipient’s name
5 Recipient’s SSN
6 Recipient’s date of birth
7 Recipient’s spouse’s name
8 Recipient’s spouse’s SSN
9 Recipient’s spouse’s date of birth
10 Policy start date
11 Policy termination date
12 Street address (including apartment no.)
13 City or town
14 State or province
15 Country and ZIP or foreign postal code
Covered Individuals
Part II
C. Covered individual
A. Covered individual name
B. Covered individual SSN
D. Coverage start date
E. Coverage termination date
date of birth
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17
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19
20
Coverage Information
Part III
A. Monthly enrollment premiums
B. Monthly second lowest cost silver
C. Monthly advance payment of
Month
plan (SLCSP) premium
premium tax credit
21 January
22 February
23 March
24 April
25 May
26 June
27 July
28 August
29 September
30 October
31 November
32 December
33 Annual Totals
1095-A
For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.
Form
(2017)
Cat. No. 60703Q
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