CMS-10466 Exemption Application - Shared Responsibility SBM's

Patient Protection and Affordable Care Act; Exchange Functions: Eligibility for Exemptions

Application_Exemption_SharedResponsibility_SBM-121813 pre508 final

Exemption Applications - Eligibility for Exemptions

OMB: 0938-1190

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-1190 can be found here:

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Form Approved
OMB No. 0938-XXXX

Application for Exemption from the Shared Responsibility
Payment for Individuals who are Unable to afford Coverage
and are in Certain States with a State Based Marketplace

Use this application
to apply for
an exemption
from the shared
responsibility
payment

• Starting in 2014, every person needs to have health insurance or
make a payment on their federal income tax return called the “shared
responsibility payment.”

Who can use this
application?

• Use this application if your state has its own Marketplace. Visit
HealthCare.gov, or call 1-800-318-2596 to see if your state has its
own Marketplace. TTY users should call 1-855-889-4325.

• Some people are exempt from making this payment. This application
includes one category of exemption, and you’ll see other categories when
you file your federal income tax return.
• You don’t need to ask for an exemption if you’re not going to file a federal
income tax return because your income is below the filing threshold. If
you aren’t sure, you may want to ask for an exemption.

• Use this application if you’re unable to afford coverage. If you get
this exemption, you may be able to buy catastrophic coverage.

THINGS TO KNOW

• Use this application to ask for an exemption for months in the future. If
you want this exemption for a whole calendar year, you need to request
it before the year starts. You can also claim an exemption on your federal
income tax return if you’re unable to afford coverage.
• You can use one application to ask for this exemption for more than one
person in your tax household.

What you need
to apply

• Social Security numbers (SSNs), if you have them.
• Employer and income information for everyone in your family (for
example, from pay stubs, W-2 forms, or wage and tax statements).
• Information about any job-related health insurance available to
your family.
• Proof of your yearly income for 2014. See page 6 for examples of
documents you can send.

Why do we ask for
this information?

We ask for Social Security numbers and other information to make sure
your exemption is counted when you file your federal income tax return.
We’ll keep all the information you give private and secure, as required
by law. To view the Privacy Act Statement, go to HealthCare.gov or
see instructions.

What happens
next?

Send your complete, signed application to the address on page 5. We’ll
follow-up with you within 1–2 weeks and let you know if we need additional
information. If you get this exemption, we’ll give you an Exemption
Certificate Number that you’ll put on your federal income tax return. If
you don’t hear from us, visit HealthCare.gov, or call the Health Insurance
Marketplace Help Center at 1-800-318-2596. TTY users should call
1-855-889-4325.
• Online: HealthCare.gov.

Get help with this
application

• Phone: Call the Health Insurance Marketplace Call Center at
1-800-318-2596.
• In person: There may be counselors in your area who can help.
Visit HealthCare.gov or call 1-800-318-2596 for more information.
• En Español: Llame a nuestro centro de ayuda gratis al
1-800-318-2596.

NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or call us at 1-800-318-2596. Para obtener una copia de este formulario en

Español, llame 1-800-318-2596. If you need help in a language other than English, call 1-800-318-2596 and tell the customer service representative
the language you need. We’ll get you help at no cost to you. TTY users should call 1-855-889-4325.

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Page 1 of 6

Use blue or black ink to complete this application.

STEP 1

Tell us about yourself.

(We need one adult in the tax household to be the contact person for your application.)
Are you in California, Colorado, the District of Columbia, Hawaii, Kentucky, Maryland, Massachusetts, Minnesota, Nevada,
New York, Oregon, Rhode Island, Vermont, or Washington?
YES. Fill out this application.
Are you in Connecticut?
YES. Visit AccessHealthCT.com, or call 1-855-805-HEALTH (1-888-805-4325) to find out how to apply for this exemption.
Are you in another state?
YES. Use the “Application for Exemption from the Shared Responsibility Payment for Individuals who are Unable to Afford
Coverage and are in a State with a Federally Facilitated Marketplace.”
1. First name

Middle name

Last name

Suffix

2. Home address (Leave blank if you don’t have one.)

4. City

3. Apartment or suite number

5. State

6. ZIP code

7. County

8. Mailing address (if different from home address)

10. City

11. State

14. Phone number

(

9. Apartment or suite number

)

–

16. Do you want to get information about this application by email?

12. ZIP code

13. County

15. Other phone number

(

Yes

)

–

Email address:
17. What is your preferred spoken or written language (if not English)?

STEP 2

Tell us about your family.

Who do you need to include on this application?
Tell us about everyone on your federal income tax return, even if they don’t need this exemption. (If you get this exemption,
you’ll need to file taxes to use it.) If you get this exemption, we’ll give you an Exemption Certificate Number with your approval
letter. Keep this for your records. You’ll need to put this number on your federal income tax return at the time you file taxes.

Complete Step 2 for each person in your family.

Start with yourself, then add other adults and children (whether or not they’re requesting an exemption). If you have more than
2 people in your family, you’ll need to make copies of page 2 and attach them. You don’t need to provide immigration status or
a Social Security number (SSN) for family members who don’t need an exemption. We’ll keep all the information you provide
private and secure as required by law. We’ll use personal information only to check if you’re eligible for an exemption.

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Page 2 of 6

STEP 2: PERSON 1

Complete Step 2 for yourself and anyone on your same federal income tax return if you file one. See page 1 for more information about who to
include. If you won’t file a tax return because you’ll have income below the filing threshold, you don’t need to request this exemption.
1. First name

Middle name

Last name

2. Relationship to you

3. Date of birth (mm/dd/yyyy)

4. Sex

5. Social Security number (SSN)

Suffix

Male

Female

If you’re requesting an exemption for yourself and you have an SSN, you must provide it. You aren’t required to have an SSN to get
this exemption. If you’re not requesting an exemption for yourself, providing your SSN can be helpful because it can speed up the
application process. We use SSNs to check income and other information to see who is eligible for an exemption, and to help make sure that
if you get an exemption, it’s applied correctly on your taxes. If you need help getting an SSN, visit socialsecurity.gov, or call 1-800-772-1213.
TTY users should call 1-800-325-0778.
6. Tell us about the federal income tax return that you plan to file.
a. Will you file jointly with a spouse?

Yes

If yes, name of spouse:
b. Will you claim any dependents on your tax return?

Yes

If yes, list name(s) of dependents:
c. Will you be claimed as a dependent on someone’s tax return?

Yes

If yes, please list the name of the tax filer:
How are you related to the tax filer?
7. Do you need this exemption?

YES.

NO. If no, leave the rest of the page blank.

8. If Hispanic/Latino, ethnicity (OPTIONAL—check all that apply.)
Mexican

Mexican American

Chicano/a

Puerto Rican

Cuban

Other

9. Race (OPTIONAL—check all that apply.)

White
Black or African
American

American Indian or
Alaska Native
Asian Indian
Chinese

Filipino
Japanese
Korean

Vietnamese
Other Asian
Native Hawaiian

Guamanian or Chamorro
Samoan
Other Pacific Islander
Other

10. YEARLY INCOME: Include wages/tips (before taxes), net income from self-employment, unemployment benefits, pensions, Social
Security (except Supplemental Security Income and old age, survivor’s or disability payments that aren’t taxable), retirement accounts,
alimony received, net farming and fishing income, net rental and royalty income, and anything else that you would include on your taxes. You
don’t need to tell us about child support or veterans’ payments.
Your total income this year

Your total income next year (if you think it will be different)

11. If your employer withholds some of your wages and uses them to pay for health insurance, list the amount that is withheld each year.

$
12. Are you offered health coverage from a job? Check “yes” even if the coverage is from someone else’s job, such as a parent or spouse.

YES. If yes, you’ll need to complete and include Appendix A.
NO.

THANKS! This is all we need to know about you.

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STEP 2: PERSON 2

If you have more than two people to include, make a copy of
Step 2: Person 2 and complete.

Page 3 of 6

Middle name

Last name

2. Relationship to you

3. Date of birth (mm/dd/yyyy)

/
-

5. Social Security number (SSN)

Suffix

4. Sex

Male

Female

If you’re requesting an exemption for PERSON 2 and PERSON 2 has an SSN, you must provide it. PERSON 2 isn’t required to have an
SSN to get this exemption. If you’re not requesting an exemption for PERSON 2, providing PERSON 2’s Social Security number (SSN)
can be helpful because it can speed up the application process. We use SSNs to check income and other information to see who is eligible
for an exemption, and to help make sure that if you get an exemption, it’s applied correctly on your taxes. If PERSON 2 needs need help
getting an SSN, visit socialsecurity.gov, or call 1-800-772-1213. TTY users should call 1-800-325-0778.
6. Tell us about the federal income tax return that PERSON 2 plans to file NEXT YEAR.
a. Will PERSON 2 file jointly with a spouse?

Yes

If yes, name of spouse:
b. Will PERSON 2 claim any dependents on his or her tax return?

Yes

If yes, list name(s) of dependents:
c. Will PERSON 2 be claimed as a dependent on someone’s tax return?

Yes

If yes, please list the name of the tax filer:
How are you related to the tax filer?
7. Does PERSON 2 need this exemption?

YES.

NO. If no, leave the rest of the page blank.

8. If Hispanic/Latino, ethnicity (OPTIONAL—check all that apply.)
Mexican

Mexican American

Chicano/a

Puerto Rican

Cuban

Other

9. Race (OPTIONAL—check all that apply.)

White
Black or African
American

American Indian or
Alaska Native
Asian Indian
Chinese

Filipino
Japanese
Korean

Vietnamese
Other Asian
Native Hawaiian

Guamanian or Chamorro
Samoan
Other Pacific Islander
Other

10. YEARLY INCOME: Include wages/tips (before taxes), net income from self-employment, unemployment benefits, pensions, Social
Security (except Supplemental Security Income and old age, survivor’s or disability payments that aren’t taxable), retirement accounts, alimony
received, net farming and fishing income, net rental and royalty income, and anything else that PERSON 2 would include on your taxes.
You don’t need to tell us about child support or veterans’ payments.
PERSON 2’s total income this year

PERSON 2’s total income next year (if you think it will be different)

11. If PERSON 2’s employer withholds some of PERSON 2’s wages and uses them to pay for health insurance, list the amount that is withheld
each year.

$
12. Is PERSON 2 offered health coverage from a job? Check “yes” even if the coverage is from someone else’s job, such as a parent or spouse.

YES. If yes, you’ll need to complete and include Appendix A.
NO.

THANKS! This is all we need to know about PERSON 2.

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STEP 3

Page 4 of 6

Lowest Cost Marketplace Plan

For anyone who is applying for this exemption who isn’t offered health coverage through a job, including a spouse or parent’s
job, your ability to get this exemption is based on the cost of the lowest-cost bronze plan that is available through your state’s
Marketplace, after applying any tax credits you can get.
This information is only available through your state’s Marketplace.
So, if anyone answered “No” to question 12 above—meaning that they aren’t offered health coverage through a job—we need
you to submit an application for health insurance to your state’s Marketplace, complete the process, and send us 2 things:
1. A copy of the eligibility notice from your state’s Marketplace that shows your maximum premium tax credit.
2. A copy of the screen from your Marketplace’s plan comparison tool that shows the premium of the lowest-cost bronze plan
available to everyone who is requesting this exemption. If there isn’t a single bronze plan that covers everyone in your tax
household who is requesting an exemption, send us the screens showing the lowest-cost bronze plans that add together to
have the lowest cost for everyone.
If you need help locating this information, you can call your state’s Marketplace. The phone numbers are listed below:

State

Phone number

California

1-800-300-1506

Colorado

1-855-PLANS-4-YOU (1-855-752-6749)

District of Columbia

1-855-532-5465

Hawaii

1-877-628-5076

Kentucky

1-855-4kynect (1-855-459-6238)

Maryland

1-855-642-8572

Massachusetts

1-877-623-6765

Minnesota

1-855-366-7873

Nevada

1-855-768-5465

New York

1-855-355-5777

Oregon

1-855-268-3767

Rhode Island

1-855-840-HSRI (1-855-840-4774)

Vermont

1-855-899-9600

Washington

1-855-WAFINDER (1-855-923-4633)

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Page 5 of 6

STEP 4

Read & sign this application.

• I’m signing this application under penalty of perjury, which means I’ve given true answers to all the questions on this form
to the best of my knowledge. I know that I may be subject to penalties under federal law if I give false and or untrue
information.
• I know that under federal law, discrimination isn’t permitted on the basis of race, color, national origin, sex, age, sexual
orientation, gender identity, or disability. I can file a complaint of discrimination by visiting www.hhs.gov/ocr/office/file.
We need this information to check your eligibility for an exemption if you choose to apply. We’ll check your answers using
information in our electronic databases and databases from the Internal Revenue Service (IRS) and/or a consumer reporting
agency. If the information doesn’t match, we may ask you to send us proof.

What should I do if I think the results of my application are wrong?

If you don’t agree with the results of your exemption application, you can ask for an appeal. Below is important information to
consider when requesting an appeal:
• The Health Insurance Marketplace must receive your appeal request within 90 days of the date of the notice of the
application results.
• You can have someone request or participate in your appeal if you want to. That person can be a friend, relative, lawyer, or
other individual. Or, you can request and participate in your appeal on your own.
• The outcome of an appeal could change the eligibility of other members of your household.
To appeal the results of your exemption application, call 1-800-318-2596. TTY users should call 1-855-889-4325. You can also mail
an appeal request form or your own letter requesting an appeal to Health Insurance Marketplace – Exemption Processing,
465 Industrial Blvd., London, KY 40741.
Sign this application. The person who filled out Step 1 should sign this application. If you’re an authorized representative you
may sign here, as long as you have provided the required information listed in Appendix B.
Signature

Date (mm/dd/yyyy)

STEP 5

Mail completed application and documents.

Mail your signed application and documents showing your yearly income (see examples on page 6) to:

Health Insurance Marketplace - Exemption Processing
465 Industrial Blvd.
London, KY 40741

PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control
number. The valid OMB control number for this information collection is 0938-XXXX. The time required to complete this information collection is estimated to
average 16 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review
the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to:
CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

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Page 6 of 6

STEP 6

Proof of Yearly Income

In order to approve you for this exemption, we need proof of your yearly income for 2014. Examples of documents you can send
include:
• Wages and tax statement (W-2)
• Pay stub
• Letter from employer
• Self-employment ledger
• Cost of living adjustment letter and other benefit verification notices
• Lease agreement
• Copy of a check paid to the household member
• Bank or investment fund statement
• Document or letter from Social Security Administration (SSA)
• Form SSA 1099 Social Security benefits statement
• Letter from government agency for unemployment benefits
These documents don’t necessarily need to be dated for 2014. For example, you can provide recent pay stubs if you don’t
expect your income to change in 2014. If you expect your income to go up or down in 2014, you can provide other documents,
like a document that states when contract work will end. If any of your income comes from freelance work, you can fill out a
self-employment ledger that includes your expected income.

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APPENDIX A: EXEMPTIONS

Form Approved
OMB No. 0938-1191

Health Coverage from Jobs

You DON’T need to answer these questions unless someone in the household is eligible for health coverage from a job. Attach a copy of this
page for each job that offers coverage.

Tell us about the job that offers coverage.

Take the Employer Coverage Tool on the next page to the employer who offers coverage to help you answer these questions. You only need to
include this page when you send in your application, not the Employer Coverage Tool.

Employee information
1. Employee name (First, Middle, Last)

2. Employee Social Security number

Employer information
3. Employer name

4. Employer Identification Number (EIN)

5. Employer address

6. Employer phone number

(
7. City

)

8. State

–
9. ZIP code

10. Who can we contact about employee health coverage at this job?

12. Email address

11. Phone number (if different from above)

(

)

–

13. Are you currently eligible for coverage offered by this employer, or will you become eligible in the next 3 months?
Yes (Continue)
13a. If you’re in a waiting or probationary period, when can you enroll in coverage? (mm/dd/yyyy)

List the names of anyone else who is eligible for coverage from this job.
Name:

Name:

No (Stop here and go to Step 5 in the application)

Tell us about the health plan offered by this employer.
14. Does the employer offer a health plan that meets the minimum value standard*?

Yes

15a. For the lowest-cost plan that meets the minimum value standard* offered only to the employee (don’t include family plans):
If the employer has wellness programs, provide the premium that the employee would pay if they don’t get a discount for wellness
programs, including smoking cessation programs.

a. How much would the employee have to pay in premiums for this plan?

b. How often?

Weekly

Every 2 weeks

Twice a month

Once a month

Quarterly

Yearly

15b. For the lowest-cost plan that meets the minimum value standard* offered to the employee and family members requesting an
exemption (only include family plans for family members that do not already have an exemption): If the employer has wellness programs,
provide the premium that the employee would pay if they don’t get a discount for wellness programs, including smoking cessation programs.

a. How much would the employee have to pay in premiums for this plan?

b. How often?

Weekly

Every 2 weeks

Twice a month

Once a month

Quarterly

Yearly

16. What change will the employer make for the new plan year (if known)?
Employer won’t offer health coverage
Employer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to the
employee that meets the minimum value standard.* (Premium shouldn’t reflect any discount for wellness programs. See question 15.)
a. How much will the employee have to pay in premiums for that plan?
b. How often?

Weekly

Every 2 weeks

c. Date of change (mm/dd/yyyy):

Twice a month

Once a month

Quarterly

Yearly

*An employer-sponsored health plan meets the “minimum value standard” if the plan’s share of the total allowed benefit costs covered by the plan is no less than
60 percent of such costs (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986).

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EMPLOYER COVERAGE TOOL: EXEMPTIONS

Form Approved
OMB No. 0938-1191

Use this tool to help answer questions in your Marketplace application, Appendix A. That part of the application asks about any employer health
coverage that you’re eligible for (even if it’s from another person’s job, like a parent or a spouse). The information in the numbered boxes below
match the boxes in Appendix A. For example, you can use the answer to question 14 on this page to answer question 14 on Appendix A.
Write your name and Social Security number in boxes 1 and 2 and ask the employer to fill out the rest of the form. Complete one tool
for each employer that offers health coverage that you’re eligible for.

EMPLOYEE information

The employee needs to fill out this section.
1. Employee name (First, Middle, Last)

2. Employee Social Security Number

EMPLOYER information

Ask the employer for this information.
3. Employer name

4. Employer Identification Number (EIN)

5. Employer address (the Marketplace will send notices to this address)

6. Employer phone number

(
7. City

)

8. State

–
9. ZIP code

10. Who can we contact about employee health coverage at this job?

12. Email address

11. Phone number (if different from above)

(

)

–

13. Is the employee currently eligible for coverage offered by this employer, or will the employee be eligible in the next 3 months?
Yes (Go to question 13a.)
13a. If the employee is not eligible today, including as a result of a waiting or probationary period, when is the employee eligible for
coverage?
(mm/dd/yyyy) (Go to next question)
No (STOP and return this form to employee)

Tell us about the health plan offered by this employer.

Does the employer offer a health plan that covers an employee’s spouse or dependent?
Yes. Which people?
Spouse
Dependent(s)
No
14. Does the employer offer a health plan that meets the minimum value standard*?
Yes (Go to question 15)

(Go to question 14)

No (STOP and return this form to employee)

a. How much would the employee have to pay in premiums for this plan?

b. How often?

Weekly

Every 2 weeks

Twice a month

Once a month

Quarterly

Yearly

a. How much would the employee have to pay in premiums for this plan?

b. How often?
Weekly
Every 2 weeks
Twice a month
Once a month
Quarterly
Yearly
If the plan year will end soon and you know that the health plans offered will change, go to question 16. If you don’t know, STOP and return
this form to employee.
16. What change will the employer make for the new plan year?
Employer won’t offer health coverage
Employer will start offering health coverage to employees or change the premium for the lowest-cost plan that meets the minimum
value standard* and is available to the employee only. (Premium shouldn’t reflect any discount for wellness programs. See question 15.)

a. How much will the employee have to pay in premiums for that plan? $

b. How often?

c. Date of change (mm/dd/yyyy):

Weekly

Every 2 weeks

Twice a month

Once a month

Quarterly

Yearly

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APPENDIX B

Form Approved
OMB No. 0938-1191

Assistance with completing this application
You can choose an authorized representative.

You can give a trusted person permission to talk about this application with us, see your information, and act for you on matters
related to this application, including getting information about your application and signing your application on your behalf.
This person is called an “authorized representative.” If you ever need to change your authorized representative, contact the
Marketplace. If you’re a legally appointed representative for someone on this application, submit proof with the application.
1. Name of authorized representative (First name, Middle name, Last name)

2. Address

3. Apartment or suite number

4. City

5. State

7. Phone number

(

)

6. ZIP code

–

8. Organization name

9. ID number (if applicable)

By signing, you allow this person to sign your application, get official information about this application, and act for you on all
future matters related to this application.
10. Your signature

11. Date (mm/dd/yyyy)

For certified application counselors, navigators, agents, and brokers only.

Complete this section if you’re a certified application counselor, navigator, agent, or broker filling out this application for
somebody else.
1. Application start date (mm/dd/yyyy)

2. First name, Middle name, Last name, & Suffix

3. Organization name

4. ID number (if applicable)

5. Agents/Brokers only: NPN number

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File Type	application/pdf
File Modified	2013-12-18
File Created	2013-12-18