Affordable Care Act Information Intake Form Lucas Accounting Page 2
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3ACA Form 1
General Information - Partial Coverage
Covered Individual (#1)
Covered Individual (#2)
First Name
First Name
Last Name
Last Name
ID Number (SSN or TIN)
ID Number (SSN or TIN)
Date of Birth
Date of Birth
1=covered all 12 months
1=covered all 12 months
Months of coverage: if not covered for all 12 months, check which
Months of coverage: if not covered for all 12 months, check which
months had coverage for at least one day:
months had coverage for at least one day:
January
January
February
February
March
March
April
April
May
May
June
June
July
July
August
August
September
September
October
October
November
November
December
December
Covered Individual (#3)
Covered Individual (#4)
First Name
First Name
Last Name
Last Name
ID Number (SSN or TIN)
ID Number (SSN or TIN)
Date of Birth
Date of Birth
1=covered all 12 months
1=covered all 12 months
Months of coverage: if not covered for all 12 months, check which
Months of coverage: if not covered for all 12 months, check which
months had coverage for at least one day:
months had coverage for at least one day:
January
January
February
February
March
March
April
April
May
May
June
June
July
July
August
August
September
September
October
October
November
November
December
December
Taxpayer's Signature: _________________________________________________________________
Z:Lori PrederAffordable Care ActAffordable Care Act Information Intake Form ACA Form 1
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