Fillable Form 1095-A - Health Insurance Marketplace Statement

Form 1095-A (2014)

Page

Instructions for Recipient

policy. This information includes the name, social security

number, date of birth (only if no social security number is

You received this Form 1095-A because you or a family member

entered in column B), and the starting and ending dates of

enrolled in health insurance coverage through the Health

coverage for each covered individual.

Insurance Marketplace. This Form 1095-A provides information

If you attested to the Marketplace at enrollment that one or

you need to complete Form 8962, Premium Tax Credit (PTC).

more of the individuals who enrolled in the plan are not

You must complete Form 8962 and file it with your tax return if

individuals for whom you intend to claim a personal exemption

you received premium assistance through advance credit

deduction on your tax return, and advance credit payments

payments (whether or not you otherwise are required to file a tax

were made, then the information reported on Form 1095‐A

return) or if you want to claim the premium tax credit when you

applies only to the individuals for whom you attested the

file your return. The Marketplace has also reported the

intention to claim a personal exemption deduction (yourself,

information on this form to the IRS. If you or your family

spouse, and dependents). For example, if you indicated to the

members enrolled at the Marketplace in more than one qualified

Marketplace at enrollment that an individual enrolling in the

health plan policy, you will receive a Form 1095-A for each

policy is your adult child for whom you will not claim a personal

policy. Check the information on this form carefully. Please

exemption deduction, that child will receive a separate Form

contact your Marketplace if you have questions concerning its

1095‐A and will not be listed in Part II on your Form 1095‐A.

accuracy.

Part II also tells the IRS the months that the individuals

Part I. Recipient Information, lines 1–15. Part I reports

identified are covered by health insurance and therefore have

information about you, the insurance company that issued your

satisfied the individual shared responsibility provision.

policy, and the Marketplace where you enrolled in the coverage.

If there are more than 5 individuals covered by a policy you

Line 1. This line identifies the state where you enrolled in

will receive one or more additional Forms 1095-A that continue

coverage through the Marketplace.

Part II.

Line 2. This line is the policy number assigned by the

Part III. Household Information, lines 21–33. Part III reports

Marketplace to identify the policy in which you enrolled. If you

information about your insurance coverage that you will need to

are completing Part 4 of Form 8962, enter this number on line

complete Form 8962 to reconcile advance credit payments or to

30, 31, 32, or 33, box a.

claim the premium tax credit when you file your return.

Line 3. This is the name of the insurance company that issued

Column A. This column is the monthly premium amount for the

your policy.

policy in which you enrolled.

Line 4. You are the recipient because you are the person the

Column B. This column is the monthly premium amount for the

Marketplace identified at enrollment who is expected to file a

second lowest cost silver plan (SLCSP) that the Marketplace

tax return and who, if qualified, would claim the premium tax

has determined applies to members of your family enrolled in

credit for the year of coverage.

the coverage. The premium for the applicable SLCSP is used to

compute your monthly advance credit payments and the

Line 5. This is your social security number. For your protection,

premium tax credit you claim on your return. See the

this form may show only the last four digits. However, the

Instructions for Form 8962, Part 2, Premium Tax Credit Claim

Marketplace has reported your complete social security number

and Reconciliation of Advance Payment of Premium Tax Credit

to the IRS.

for instructions on how to use the information in this column or,

Line 6. A date of birth will be entered if there is no social

if there is no information entered.

security number on line 5.

Column C. This column is the monthly amount of advance

Lines 7, 8, and 9. Information about your spouse will be entered

credit payments that were made to your insurance company on

only if advance credit payments were made for your coverage.

your behalf to pay for all or part of the premiums for your

The date of birth will be entered on line 9 only if line 8 is blank.

coverage. No information will be entered in this column if no

Lines 10 and 11. These are the starting and ending dates of the

advance credit payments were made.

policy.

Lines 21–33. The Marketplace will report the amounts in

Lines 12 through 15. Your address is entered on these lines.

columns A, B, and C on lines 21–32 for each month and enter

the totals on line 33. Use this information to complete

Part II. Coverage Household, lines 16–20. Part II reports

Form 8962, line 11 or lines 12–23.

information about each individual who is covered under your

Form 1095-A - Health Insurance Marketplace Statement - 2014 Page 2

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