Information Collection

Form 1095-A- Health Insurance Marketplace Statement

IC 213666 under ICR 201410-1545-025 · OMB 1545-2232.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1545-2232 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1095-A Form 1095-A- Health Insurance Marketplace Statement	Form
Instr for Form 1095-A.pdf	Instruction
1095-A Health Insurance Marketplace Statement Form 1095-A.pdf	Form

IC Title:

Form 1095-A- Health Insurance Marketplace Statement

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
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

Line of Business: General Government

Subfunction: Taxation Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 15

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	2,000,000	2,000,000
Annual IC Time Burden (Hours)	11,250	11,250
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.