Form Obma - Obamacare Individual Mandate Tax Compliance Form

Obamacare Individual Mandate

OBMA

OMB No. 359

Form

Tax Compliance Form

Department of the Treasury

Internal Revenue Service (99)

Name of individual subject to additional tax. If married filing jointly, see instructions.

Your social security number

Home address (number and street), or P.O box if mail is not delivered to your home

Apt. no.

Fill in Your Address Only

If You Are Filing This

Form by Itself and Not

City, town or post office, state, and ZIP code

If this is an amended

With Your Tax Return

return, check here ►

Health Care Information

Part I

Date of Birth

Spouse Date of Birth

Family Size

1 Indicate the time period you were covered by qualifying health insurance (see Instruction A) . . .

Full Year or Part Year

Not Covered

Employer Plan

Individual Plan in an Exchange

2 What type of qualifying health insurance plan were you covered by? (See instruction B) . . . . . .

Individual Plan Not in an Exchange

Medicaid

Medicare

VA Benefits or Tricare

Name of Insurer

Insurer EIN

Personal Health ID Number

3 Your Health Insurance Information (see Instruction C)

Name of Insurer

Insurer EIN

Personal Health ID Number

4 Spouse Health Insurance Information (see Instruction C)

Affordability

Part II

5 Did your employer offer affordable qualifying coverage? (See Instruction D) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

6 Were you eligible for government-subsidized health insurance? (See Instruction E) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

7 Were you able to purchase affordable health insurance? (See Instruction F) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

Exemption

Part III

8 Are you claiming a religious exemption from the individual responsibility mandate? (See Instruction G) . . . . . . . . . . . . . . . . . . . . . .

Yes

9 Are you an incarcerated criminal and therefore exempt from the personal mandate? (See Instruction H) . . . . . . . . . . . . . . . . . . . . .

Yes

10 Are you an illegal immigrant and therefore exempt from the personal mandate? (See Instruction I) . . . . . . . . . . . . . . . . . . . . . . . .

Yes

11 Have you received a certificate of exemption from the federal Department of Health and Human Services? (See Instruction J) . . . . . . . . .

Yes

Individual Mandate Compliance Penalty Tax

Part IV

13 Tax penalty (see Instruction L)

12 What months were you covered by an affordable qualifying health insurance plan? (See Instruction K)

January

February

March

April

May

June

July

August

September

October

November

December

Sign

Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge and

belief, they are true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.

Here

Your signature

Date

Your occupation

Daytime phone number

Keep a copy for your

records.

Spouse’s signature. If a joint return, both must sign.

Date

Spouse’s occupation

If the IRS sent you an Identity Protection

PIN, enter it

here (see inst.)

In the event that President Obama is re-elected, please consult your tax preparation specialist on the appropriate information you may need to collect in addition to the

information requested by this form. Failing to comply with the Obamacare Tax Mandate could result in severe financial penalties and interest against your personal property.

If Mitt Romney defeats President Obama on Election Day, November 6, 2012, and Republicans take control of the Senate and maintain their majority in the US House, you

may disregard this form as Romney has promised to repeal Obamacare.

For additional information, go to

This is an estimated form based on the requirements of the 2010 Affordable Healthcare Act (“Obamacare”) and was not created at US government expense.