Instructions For Form 1 - Massachusetts Resident Income Tax - 2013 Page 7
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442013 Schedule HC — Line by Line Instructions
(e) Your family size was so large that reliance on
If you file an appeal, you will be required to state
If you (and/or your spouse, if married filing
the affordability schedule (see Table 3: Affordabil-
your grounds for appealing, and provide further
jointly) fill in that oval on your return, you will re-
ity) to deter mine how much you could afford to
information and supporting documentation. Any
ceive a follow-up letter from the Connector Au-
pay for health insurance is inequitable.
statements and claims you make will be under
thority asking you to state your grounds for appeal
pains and penalties of perjury.
in writing, and submit supporting documentation.
(f) During 2013 you purchased health insurance
Failure to respond to that form within the time
that did not meet Minimum Creditable Coverage
How to Appeal
specified will lead to dismissal of your appeal.
requirements, but which was close to or substan-
To appeal, you must fill in the oval for you (and
Also, you (and/or your spouse, if married filing
tially met those requirements, and you felt that
your spouse, if applicable) on Schedule HC, Ap-
jointly) are allowed only one opportunity to ap-
your circumstances prevented you from buying
peals Section that authorizes DOR to share infor-
peal. The Connector Authority will then review the
other insurance that met the requirements.
mation in your tax return, including Schedule HC,
information you provided. You may be required to
(g) During 2013 you purchased health insurance
with the Commonwealth Health Insurance Connec -
participate in a hearing on your case. You will be
that did not meet Minimum Creditable Coverage
tor Authority, the independent state body that will
required to state your claims under pains and pen -
requirements because that is all that your employer
hear the appeal. No penalty will be assessed by
alties of perjury.
offered, and you felt that your circumstances pre-
DOR pending the outcome of your appeal.
Note: Do not include any hardship documentation
vented you from buying other insurance that met
Note: If you are filing an appeal, make sure you
with your original return. You will be required to
the requirements.
have calculated the penalty amount that you are
submit substantiating hardship documentation at
You may also base your appeal on other circum-
appealing, but do not assess yourself or enter a
a later date during the appeal process.
stances, such as the application of the affordability
penalty amount on your income tax return.
tables in Schedule HC to you is inequitable (for ex -
ample, due to fluctuations in income or other
changes in life circumstances that affect financial
status during the year), you were unable to obtain
government-subsidized insurance despite your in-
come, or other circumstances that made you un-
able to purchase insurance despite your income.
HC-5
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