Instructions For Form 8965 - Health Coverage Exemptions

Instructions For Form 8965 - Health Coverage Exemptions - 2016 Page 18

Worksheet A

Use this worksheet if you were referred here from Step 1 under

Shared Responsibility

Payment. After completing the worksheet, go

to Step 3 under Shared Responsibility Payment. 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 the monthly columns by placing “Xs” in each month in which you or another member of your tax household had neither minimum

essential coverage nor a coverage exemption.

Name

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

1. Add the total number of Xs in a month. If 5

or more, enter 5

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

2. Add the total number of Xs in a month for

individuals 18 or over*

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

3. Enter one-half the number of Xs in a month

for individuals under 18*

. . . . . . . . . .

4. Add lines 2 and 3 for each month

. . . . .

5. Multiply line 4 by $695 for each month. If

$2,085 or more, enter $2,085

. . . . . . . .

6. Add the amounts for each month on line 5

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

7. Divide line 6 by 12.0. This is your flat dollar amount. Enter this amount on line 1 of the Shared Responsibility

Payment Worksheet

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

8. Add the total number of Xs entered for each month on line 1. Go to Step 3

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

*For purposes of figuring the shared responsibility payment, an individual is considered under 18 for an entire month if he or she didn't turn 18 before the first

day of the month. An individual turns 18 on the anniversary of the day the individual was born. For example, someone born on March 1, 2001, is considered

age 18 on March 1, 2019, and, therefore, isn't considered age 18 for purposes of the shared responsibility payment until April 2019.

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