8965
OMB No. 1545-0074
Health Coverage Exemptions
2014
Form
Attach to Form 1040, Form 1040A, or Form 1040EZ.
▶
Department of the Treasury
Attachment
Information about Form 8965 and its separate instructions is at
75
▶
Internal Revenue Service
Sequence No.
Name as shown on return
Your social security number
Complete this form if you have a Marketplace-granted coverage exemption or you are claiming a coverage exemption
on your return.
Marketplace-Granted Coverage Exemptions for Individuals: If you and/or a member of your tax household
Part I
have an exemption granted by the Marketplace, complete Part I.
a
b
c
Name of Individual
SSN
Exemption Certificate Number
1
2
3
4
5
6
Part II
Coverage Exemptions for Your Household Claimed on Your Return:
Are you claiming an exemption because your household income is below the filing threshold? .
.
.
.
.
.
7a
Yes
No
b
Are you claiming a hardship exemption because your gross income is below the filing threshold?
.
.
.
.
Yes
No
Coverage Exemptions for Individuals Claimed on Your Return: If you and/or a member of your tax
Part III
household are claiming an exemption on your return, complete Part III.
c
d
a
b
e
f
g
h
i
j
k
l
m
n
o
p
Exemption
Full
Name of Individual
SSN
Jan
Feb
Mar
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
Type
Year
8
9
10
11
12
13
8965
For Privacy Act and Paperwork Reduction Act Notice, see your tax return instructions.
Form
(2014)
Cat. No. 37787G