Instructions For Form 8965 - Health Coverage Exemptions - 2016 Page 16
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20Percentage Income Amount
Step 4
3. Did you attach Form 2555 or Form 2555-EZ?
Yes. Enter the amount
No. Continue
1. Enter your household income from Step 3.
from Form 2555, lines
45 and 50; or Form
1
2555-EZ, line 18.
3
2. Were you or your spouse (if filing jointly) born before
January 2, 1953?
Yes. Skip question 3.
No. Go to question 3.
4. Did you claim any dependents?
Find your filing
Yes. Continue
threshold on the Filing
No.
STOP
Thresholds for Most
People chart and enter
Add lines 1 through 3.
it both here and on
This is your household
line 4.
income. Enter the result
on Step 4, line 1.
2
5. Were any of the dependents you claimed required to file a
return?
Yes. Complete
No. Add lines 1 through
questions 1 through 3
3. This is your
3. Enter the amount listed below for your filing status.
for each dependent with
household income.
Single—$10,400
a filing requirement for
Enter the result on Step
Head of household—$13,400
whom you didn’t
4, line 1.
Married filing jointly—$20,800
attach Form 8814.
Married filing separately—$4,050
Enter the total here.
Qualifying widow(er)—$16,750
3
5
4. Enter the amount from line 2 or 3.
6. Did you attach Form 8814?
4
Yes. Continue
No.
STOP
Add lines 1, 2, 3, and 5.
This is your household
income. Enter the result
5. Subtract line 4 from line 1.
on Step 4, line 1.
5
7. Is Form 8814, line 4, more than $1,050?
Yes. Add the amount
No. Enter -0- below.
from Form 8814,
6. Is the amount on line 5 zero or less?
Continue
line 1b, and the smaller
No. Continue
Yes.
of Form 8814, line 4 or
STOP
5.
You don’t owe a shared
responsibility payment.
Complete Form 8965
7
by checking the box on
line 7.
7. Multiply line 5 by 2.5% (0.025). This is your percentage
8. Add lines 1, 2, 3, 5, and 7. This is your household
income amount.
income. Enter the result on Step 4, line 1.
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-16-
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