Schedule Hc - Health Care Information - 2014 Page 3
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42014 SCHEDULE HC, PAGE 2
SOCIAL SECURITY NUMBER
FIRST NAME
M.I.
LAST NAME
Schedule HC Uninsured for All or Part of 2014
Do NOT complete if you are not subject to a penalty.
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Was your income in 2014 at or below 150% of the federal poverty level (see worksheet)?
3 6
Yes
No
If you answer Yes,
YOU ARE NOT SUBJECT TO A PENALTY IN 2014. 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 2014,
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.
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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 2014. 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 2014, 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 2014.
YOU ARE NOT SUBJECT TO A PENALTY IN 2014.
SKIP THE REMAINDER OF THIS SCHEDULE AND COMPLETE YOUR TAX RETURN.
Schedule HC Religious Exemption and Certificate of Exemption
Do NOT complete if you are not subject to a penalty.
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a. RELIGIOUS EXEMPTION. Are you claiming an exemption from the requirement to purchase
3 8a You:
Yes
No
health insurance based on your sincerely held religious beliefs that cause you to object to
Spouse:
Yes
No
substantially all forms of treatment covered by health insurance?
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
3 8b You:
Yes
No
the 2014 tax year?
Spouse:
Yes
No
If you answer No to line 8b,
YOU ARE NOT SUBJECT TO A PENALTY IN 2014. SKIP THE REMAINDER OF THIS SCHEDULE AND CONTINUE
COMPLETING 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.
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CERTIFICATE OF EXEMPTION. Have you obtained a Certificate of Exemption issued by the
3 9 You:
Yes
No
Commonwealth Health Insurance Connector Authority for the 2014 tax year?
Spouse:
Yes
No
Note: If you received a Certificate of Exemption from the Federal shared responsibility requirement in 2014, issued by the Federal Health
Insurance Marketplace, do not enter that information in line 9.
If you answer Yes, enter the certificate number below,
YOU ARE NOT SUBJECT TO A PENALTY IN 2014. 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 MASSACHUSETTS CERTIFICATE NUMBER
SPOUSE’S MASSACHUSETTS CERTIFICATE NUMBER
BE SURE TO ENCLOSE SCHEDULE HC WITH YOUR RETURN.
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