Instructions For Form 8965 - Health Coverage Exemptions - 2016 Page 17
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20complete line 5 of the
Shared Responsibility Payment
Worksheet.
8. Were you required to complete Worksheet A?
Yes. Go to
No. Enter the amount
2
Worksheet B. Then
from line 7 above on
continue to Step 5.
line 2 of the Shared
Responsibility Payment
Worksheet and complete
*$272 is the 2017 national average premium for a bronze level health plan available
line 3 of that worksheet.
through the Marketplace for one individual for one month.
Then continue to Step 5.
National Average Bronze Plan
Step 5
3. Enter on line 4 of the
Shared Responsibility Payment
Premium
Worksheet, the amount below that corresponds to the total
number of number of people in your tax household. Then
complete line 5 of the
Shared Responsibility Payment
1. Were you required to complete Worksheet A?
Worksheet.
Yes. Continue
No. Skip question 2; Go
1 person—$3,264
to question 3.
2 people—$6,528
3 people—$9,792
4 people—$13,056
2. Multiply $272* by the number on
Worksheet
A, line 8.
5 or more people—$16,320
Enter the result here and on line 4 of the
Shared
Responsibility Payment
Worksheet. Skip question 3 and
Shared Responsibility Payment Worksheet
Use this worksheet if you are referred here from the Shared Responsibility Payment flowchart or from Worksheet A or B. If
everyone in your tax household had either minimum essential coverage or a coverage exemption for every month during
2017, stop here. You don’t owe a shared responsibility payment.
Complete Step 1
1. Enter the flat dollar amount. (From Step 2, question 4 or Worksheet A, line 7)
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. . . . . . . . . . . . . . . .
Complete Step 3
2. Enter the percentage income amount. (From Step 4, question 7 or Worksheet B, line 14)
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. . . . . . . . .
3. Enter the larger of line 1 or line 2
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Complete Step 5
4. Enter the National Average Bronze Plan Premium. (From Step 5, question 2 or 3)
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5. Enter the smaller of line 3 or line 4 here and on Form 1040, line 61; Form 1040A, line 38; or Form
1040EZ, line 11. This is your shared responsibility payment
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