Obamacare Tax Form Exemptions Questionnaire printable pdf download

ACA (aka ObamaCare) “Exemptions” Questionnaire

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must have

a. Exemptions granted by the Health Care Marketplace and you

the Exemption Certificate

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Hardship

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Religious objection

b. Exemptions available by claiming them on your tax return

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No Code - Income below filing requirements – income is less than standard deduction plus exemptions

Code A – Coverage considered unaffordable – you cannot afford coverage because the minimum amount

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you must pay for premiums is more than 8% of your household income (combined income of all

persons listed on the tax return , but does not include income earned by children who are not

required to file)

Code B - Short-coverage gap period – lack of coverage was less than 3 months

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Code C - Citizens living abroad and certain noncitizens (persons with an ITIN)

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Code D - Members of a health care sharing ministry

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Code E - Indian tribe members

Code F - Incarcerated

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Code G – Two or more family members cost of each self-only employer-sponsored coverage is more than

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8% of household income, which includes any tax exempt interest.

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Code G - You purchased Marketplace insurance but have a coverage gap at the beginning of 2014

Code G - You applied for CHIP coverage but have a coverage gap at the beginning of 2014

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Code G - Resident of non-Medicaid expansion state

(Indiana)

and household income below 138% of FPL

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Code H - Enrolled in Medicaid or TRICARE programs that are not considered minimum essential coverage

Code H - Fiscal year employer-sponsored plan that you were eligible for but did not purchase

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(5) Name: Please list the name of every person who received an exemption or who is eligible for an exemption

(6) Exemption: Please list which exemption you believe applies to you (we can help with the unaffordable exemptions)

(7) Covered Period: If exemption is for the full year, check the “Full Year” box

If exemption is not for the full year, check the monthly boxes for which the exemption applies

Full

Months Exemption Applies

Name

Exemption

Year Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

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I have disclosed the above information to my income tax preparer for them to prepare my 2014 income tax return and

I further certify that this information is correct to the best of my knowledge.

Signature:

Date:

Reviewed:

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________________

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Obamacare Tax Form Exemptions Questionnaire

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