Form Obma - Obamacare Individual Mandate Tax Compliance Form

Instructions for Completing

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A. Time Period. Indicate whether you

E. Government subsidized. You are

H. Incarcerated Criminals. Incarcer-

were covered for part or all of the year

eligible

for

government-subsidized

ated individuals are exempt from the

by a “qualifying health insurance plan”

health insurance if you are: over age

individual mandate.

as defined by the federal Department

65 and enrolled in Medicare; earn less

of Health and Human Services. If you

than the federal poverty level and are

I. Illegal Immigrants. Individuals who

were only covered for part of the year,

enrolled in Medicaid; are covered as

are in the United States and are undocu-

you may be required to make an indi-

an active military person under Tri-

mented are exempt from the individual

vidual mandate penalty payment to the

care; are a veteran receiving benefits

mandate.

IRS.

under the Veterans’ Administration; or

earn less than 400 percent of the fed-

J. Certificate. You can apply to the

B. Type of Plan. This should be indi-

eral poverty level and will be receiv-

Secretary of the Department of Health

cated on the tax form you were mailed

ing a refundable, advancable tax credit

and Human Services for a waiver from

by your health insurance company.

under the Affordable Care Act. In the

Obamacare. Consult your registered

A copy of this tax form has also been

final case, the money has already been

lobbyist in Washington, D.C.

mailed to the IRS for their confirmation

collected by your insurance company

K. Months Covered. If you were not

of your plan status.

and you have to account for it on your

tax return.

covered by qualifying affordable health

C. Health Insurance Information.

insurance for part of the year, you will

Be sure to include the health insurance

F. Affordable. You must purchase

have to pay a penalty for those months

plan, identification number, and per-

qualifying health insurance (or pay the

which you were uninsured.

sonal health information number (for

individual mandate penalty tax to the

both you and your spouse) as found

IRS) unless an affordable health insur-

L. Penalty. To calculate this number,

on the tax form mailed to you by your

ance plan is not available to you. An

first multiply your adjusted gross in-

health insurance company and copied

affordable plan is one which costs you

come by 2.5%. If this number is bigger

to the IRS.

no more than 8 percent of your adjusted

than $695 (single), $1390 (family with

gross income out-of-pocket.

two persons), or $2085 (family with

D. Employer Qualifying Coverage.

three or more persons), pay this higher

Does your employer offer health insur-

G. Religious Exemption. The individ-

number. If the dollar figure listed here

ance coverage that is deemed “quali-

ual mandate is waived only for those

is bigger, pay that dollar figure. Pro-

fied” under the Affordable Care Act?

persons belonging to a religion which

rate by the number of months you did

This plan must include necessary pre-

explicitly rejects having health insur-

not enroll in an affordable, qualifying

ventive coverage such as contracep-

ance as a tenant of its faith. If you have

health insurance plan.

tion, abortion, and hair loss treatment.

another conscience objection, you need

Your employer insurance premium

to apply for a waiver to the Department

amounts should be listed on your W-2.

of Health and Human Services.

Form Obma - Obamacare Individual Mandate Tax Compliance Form - 2014 Page 2

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