Instructions For Form 1095-A - Health Insurance Marketplace Statement - 2016 Page 3

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provided a tool for determining the applicable SLCSP
discovering that information reported is incorrect. Check
premium for the year of coverage at the time of filing the
the corrected box on the top of the form.
tax return, leave column B blank. If the Marketplace has
Privacy Act and Paperwork Reduction Act Notice.
not provided a tool for determining the applicable SLCSP
We ask for the information on this form to carry out the
premium, enter the premiums for the SLCSP that would
Internal Revenue laws of the United States. You are
apply to all individuals identified in Part II as covered for
required by the Internal Revenue Code to give us the
the month.
information. We need it to ensure that taxpayers are
If a policy is terminated by an issuer for nonpayment of
complying with these laws and to allow us to figure and
premiums and advance credit payments are made,
collect the right amount of tax.
enter -0- for a month in which the covered individuals
have coverage but the premiums aren't paid (generally,
You aren't required to provide the information
the first month of a grace period). However, if an individual
requested on a form that is subject to the Paperwork
enrolled on the first day of a month terminates coverage
Reduction Act unless the form displays a valid OMB
before the last day of the month, the individual should be
control number. Books or records relating to a form or its
considered to have been enrolled for the entire month for
instructions must be retained as long as their contents
purposes of the applicable SLCSP premium reported in
may become material in the administration of any Internal
column B.
Revenue law. Generally, tax returns and return
information are confidential, as required by IRC section
Column C. Enter the amount of advance credit payments
6103.
for the month. If more than one Form 1095-A is filed for
coverage of a tax filer’s family for the same months, enter
The time needed to complete and file this form will vary
only the advance credit payment amount allocated to the
depending on individual circumstances. The estimated
policy reported on this Form 1095-A. If the tax filer’s family
average time is:
is also enrolled in a stand-alone dental plan, any advance
credit payments allocated to the stand-alone dental plan
Preparing the form
.3 min.
. . . . . . . . . . . .
should be added to the advance credit payments
allocated to one of the policies reported on a Form
1095-A.
If you have comments concerning the accuracy of
these time estimates or suggestions for making this form
Void Statements
simpler, we would be happy to hear from you. You can
If a Form 1095-A was sent for a policy that shouldn't be
send us comments from Click on
reported on a Form 1095-A, such as a stand-alone dental
“More Information” and then on “Give us feedback.” Or
plan or a catastrophic health plan, send a duplicate of that
you can write to the Internal Revenue Service, Tax Forms
Form 1095-A and check the void box at the top of the
and Publications Division, 1111 Constitution Ave. NW,
form. Provide this information to the IRS and to the
IR-6526, Washington, DC 20224. Don't send the form to
recipient of the statement as soon as possible after
this office.
discovering that the statement was sent in error.
Correction to Information Reported
Report corrected information on the Form 1095-A to the
IRS and to the recipient as soon as possible after
-3-
Instructions for Form 1095-A (2016)

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