Fillable Schedule Hc - Health Care Information

2014 SCHEDULE HC, PAGE 3

SOCIAL SECURITY NUMBER

FIRST NAME

M.I.

LAST NAME

Schedule HC Affordability as Determined By State Guidelines

Do NOT complete if you are not subject to a penalty.

NOTE: This section will require the use of worksheets and tables. You must complete the worksheet(s) to determine if health insurance was

affordable to you during the 2014 tax year.

Did your employer offer affordable health insurance that met the minimum creditable coverage

3 10 You:

Yes

requirements as determined by completing the Schedule HC Worksheet for Line 10?

Spouse:

Yes

If your employer did not offer health insurance that met the minimum creditable coverage requirements, you were not eligible for health insur-

ance offered by your employer, you were self-employed or you were unemployed, fill in the No oval.

If you answer No, go to line 11. If you answer Yes, go to the Health Care Penalty Worksheet to calculate your penalty amount.

Were you eligible for government-subsidized health insurance as determined by completing

3 11 You:

Yes

the Schedule HC Worksheet for Line 11?

Spouse:

Yes

If you answer No, go to line 12. If you answer Yes, go to the Health Care Penalty Worksheet to calculate your penalty amount.

Were you able to purchase affordable private health insurance that met the minimum creditable

3 12 You:

Yes

coverage requirements as determined by completing the Schedule HC Worksheet for Line 12?

Spouse:

Yes

If you answer No, you are not subject to a penalty.

CONTINUE COMPLETING YOUR TAX RETURN.

If you answer Yes, go to the Health Care

Penalty Work sheet to calculate your penalty amount.

Schedule HC Complete Only If You Are Filing an Appeal

You must complete the Health Care Penalty Worksheet to determine your penalty amount before completing this section.

You may have grounds to appeal if you were unable to obtain affordable insurance that met the minimum creditable coverage requirements

in 2014 due to a hardship or other circumstances. The grounds for appeal are explained in more detail in the instructions. If you believe you

have grounds for appealing the penalty, fill in the oval(s) below. The appeal will be heard by the Commonwealth Health Insurance Connector

Authority. By filling in the oval below, you (or your spouse if married filing jointly) are authorizing DOR to share information from your tax

return, including this schedule, with the Connector Authority for purposes of deciding your appeal.

Note: You may also be subject to a separate federal penalty if you were uninsured. Visit irs.gov for more information on the federal requirements.

If you are subject to a federal penalty, you must enter that amount on Form 1, line 34c or Form 1-NR/PY, line 39c.

Important Information If You Are Filing An Appeal:

You will receive a follow-up letter asking you to state your grounds for appeal in writing, and submit supporting documentation. Failure

to respond to that letter within the time specified in the letter will lead to dismissal of your appeal and will result in a future assessment

of a penalty.

Once your documentation is received, it will be reviewed by the Commonwealth Health Insurance Connector Authority and you may be re -

quired to attend a hearing on your case. You will be required to file your claims under the pains and penalties of perjury.

Note: If you are filing an appeal, make sure you have calculated the penalty amount that you are appealing, but do not assess yourself or enter

a penalty amount on your Form 1 or Form 1-NR/PY. Also, do not include any hardship documentation with your original return. You will be

required to submit substantiating hardship documentation at a later date during the appeal process.

YOU:

I wish to appeal the penalty. I authorize DOR to share this tax return including this schedule with the Commonwealth Health

Insurance Connector Authority for purposes of deciding this appeal.

SPOUSE:

I wish to appeal the penalty. I authorize DOR to share this tax return including this schedule with the Commonwealth Health

Insurance Connector Authority for purposes of deciding this appeal.

BE SURE TO ENCLOSE SCHEDULE HC WITH YOUR RETURN.

Schedule Hc - Health Care Information - 2014 Page 4

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