Form 1095-A- Health Insurance Marketplace Statement

Health Insurance Premium Tax Credit

OMB: 1545-2232

IC ID: 213666

Information Collection (IC) Details

View Information Collection (IC)

Form 1095-A- Health Insurance Marketplace Statement
 
No New
 
Mandatory
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form 1095-A Health Insurance Marketplace Statement Form 1095-A.pdf Yes Yes Fillable Fileable
Instruction Instr for Form 1095-A.pdf Yes No Printable Only

General Government Taxation Management

 

15 0
   
Private Sector Not-for-profit institutions, Businesses or other for-profits
 
   50 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 2,000,000 0 0 2,000,000 0 0
Annual IC Time Burden (Hours) 11,250 0 0 11,250 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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