Form 1095-A - Health Insurance Marketplace Statement - 2014

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Health Insurance Marketplace Statement
OMB No. 1545-2232
Information about Form 1095-A and its separate instructions
Department of the Treasury
is at
Internal Revenue Service
Recipient Information
Part I
1 Marketplace identifier
2 Marketplace-assigned policy number
3 Policy issuer's name
4 Recipient's name
5 Recipient's SSN
6 Recipient's date of birth
7 Recipient's spouse's name
8 Recipient's spouse's SSN
9 Recipient's spouse's date of birth
10 Policy start date
11 Policy termination date
12 Street address (including apartment no.)
13 City or town
14 State or province
15 Country and ZIP or foreign postal code
Coverage Household
Part II
C. Covered Individual
D. Covered Individual
E. Covered Individual
A. Covered Individual Name
B. Covered Individual SSN
Date of Birth
Start Date
Termination Date
Household Information
Part III
A. Monthly Premium Amount
B. Monthly Premium Amount of Second
C. Monthly Advance Payment of
Lowest Cost Silver Plan (SLCSP)
Premium Tax Credit
21 January
22 February
23 March
24 April
25 May
26 June
27 July
28 August
29 September
30 October
31 November
32 December
33 Annual Totals
For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.
Cat. No. 60703Q


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