Schedule Hc - Health Care Information - 2013 (Page 2 of 3) in pdf

2013 SCHEDULE HC, PAGE 2

SOCIAL SECURITY NUMBER

FIRST NAME

M.I.

LAST NAME

Uninsured for All or Part of 2013

Was your income in 2013 at or below 150% of the federal poverty level (see worksheet)?

Yes

If you answer Yes, you are not subject to a penalty in 2013. Skip the remainder of this schedule and complete your tax return. If you answer

No and you were enrolled in a health insurance plan that met the MCC requirements for part, but not all, of 2013, go to line 7. If you answer

No and you had no insurance or you were enrolled in a plan that did not meet the MCC requirements during the period that the mandate

applied, go to line 8a.

Complete this section only if you, and/or your spouse if married filing jointly, were enrolled in a health insurance plan(s) that met the Minimum

Creditable Coverage (MCC) requirements for part, but not all of 2013. Fill in the ovals below for the months that met the MCC requirements,

as shown on Form MA 1099-HC. If you did not receive this form, fill in the ovals for the months you were covered by a plan that met the MCC

requirements at least 15 days or more. If, during 2013, you turned 18, you were a part-year resident or a taxpayer was deceased, fill in the

oval(s) below for the month(s) that met the MCC requirements during the period that the mandate applied. See instructions.

You may only fill in the oval(s) for the month(s) you had health insurance that met MCC requirements. If you had health insurance, but it did

not meet MCC requirements, you must skip this section and go to line 8a.

MONTHS COVERED BY HEALTH INSURANCE THAT MET MINIMUM CREDITABLE COVERAGE

JAN

FEB

MARCH

APRIL

MAY

JUNE

JULY

AUG

SEPT

OCT

NOV

DEC

YOU:

SPOUSE:

If you had four or more consecutive months either with no insurance or insurance that did not meet the MCC requirements (four or more

blank ovals in a row), go to line 8a. Otherwise, a penalty does not apply to you in 2013. Skip the remainder of this schedule and complete

your tax return.

Religious Exemption and Certificate of Exemption

a. RELIGIOUS EXEMPTION. Are you claiming an exemption from the requirement to purchase

8a You:

Yes

health insurance based on your sincerely held religious beliefs?

Spouse:

Yes

If you answer Yes, go to line 8b. If you answer No, go to line 9. If you are filing a joint return and one spouse answers Yes but the other

spouse answers No, see instructions.

b. If you are claiming a religious exemption in line 8a, did you receive medical health care during

8b You:

Yes

the 2013 tax year?

Spouse:

Yes

If you answer No to line 8b, skip the remainder of this schedule and continue com pleting your tax return. If you answer Yes to line 8b, go

to line 9. If you are filing a joint return and one spouse answers Yes but the other spouse answers No, see instructions.

CERTIFICATE OF EXEMPTION. Have you obtained a Certificate of Exemption issued by the

9 You:

Yes

Commonwealth Health Insurance Connector Authority for the 2013 tax year?

Spouse:

Yes

If you answer Yes, enter the certificate number below, skip the remainder of this schedule and continue completing your tax return. If you an -

swer No to line 9, go to line 10. If you are filing a joint return and one spouse answers Yes but the other spouse answers No, see instructions.

YOUR CERTIFICATE NUMBER

SPOUSE’S CERTIFICATE NUMBER

BE SURE TO ENCLOSE SCHEDULE HC WITH YOUR RETURN.

Schedule Hc - Health Care Information - 2013 Page 2

Related Articles

Related forms

Related Categories