Affordable Care Act Information Intake Form Lucas Accounting printable pdf download

Affordable Care Act Information Intake Form

Taxpayer's Name: ____________________________________________________

Indicate only one of the first three lines

_____

Check here if ENTIRE Household had Minimum Essential Coverage* for ALL Months of the Year

*Definition of Minimum Essential Coverage is available - ask a member of our staff or follow this link

-If you received your coverage from the Marketplace, you MUST provide form 1095-A

-You may have received form 1095-B from a Health Insurance Provider - If so, please provide us with it.

-You may have received form 1095-C from your Employer - if so, please provide us with it.

-If you have no 1095, retain proof of coverage in your personal files as you may be required to

provide it in the event of an audit.

If you checked line 1, STOP, you are done with this form. Sign at the bottom.

_____

Check here if ENTIRE Household had NO Coverage for the ENTIRE Year

If selected, go to line 4

_____

Check here if Partial Coverage - Some, but not all, household members and/or some, but

not all, months of the year

If Partial Coverage is indicated, then we need specific details of which family members

were covered for which months of the year. See page at the end of your organizer or

complete ACA Form 1 (available from our staff or in this workbook on page 2)

For months of no coverage, go to line 4

For months of no coverage, indicate whether you already have an exemption or believe

you qualify for an exemption**.

**A list of exemptions is available - see a member of our staff or follow this link

_____

Already have an exemption or qualify for an exemption

_____

Not exempt

If not exempt, then STOP, you are done with this form. Sign at the bottom.

If you are exempt, then indicate which exemption applies for which months of the year

Complete ACA Form 2 (available from our staff or in the workbook on page 3)

If you have an exemption certificate from the Marketplace, you must provide it before we

can complete your return.

Taxpayer's Signature: ________________________________________________________

Z:Lori PrederAffordable Care ActAffordable Care Act Information Intake Form Intake Info

Affordable Care Act Information Intake Form Lucas Accounting