Form CMS-10466 Application Exemptions Shared Responsibility for FFM's

Patient Protection and Affordable Care Act; Exchange Functions: Eligibility for Exemptions (CMS-10466)

CMS-10466 - affordability-ffm-exemption_FINAL(ADOBE)

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⚠️ Notice: This form may be outdated.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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XX/2017

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

DRAFT MOCKUP
OMB No. 0938-1190

• Every person needs to have health coverage or make a payment on his or her

federal income tax return. This is called the “shared responsibility payment.”

• Some people are eligible for an exemption from making this payment. This

application includes one category of exemption. There are other applications
for other categories of exemptions. You may apply for certain other categories
of exemptions when you file your federal income tax return.

• You don’t need to apply for an exemption if you’re not going to file a federal

income tax return. If you’re not sure you’ll file a tax return, you may want to
apply for an exemption anyway.

Who can use this
application?

• Use this application if you’re unable to afford coverage. If you get this

When can you get
this exemption?

• Use this application to ask for an exemption for months in the future. You

What you may
need to apply

• Social Security numbers (SSNs), if you have them.

exemption, you may be able to buy catastrophic coverage.

• You must list everyone in your tax household on a single application.

can’t get this exemption for time in the past. If you want this exemption for an
entire calendar year, you need to request it before January 1 of that year. If
you need this exemption for months in the past, you can apply for it when you
file your tax return instead.

• Employer and income information for everyone in your tax household

(for example, from pay stubs, W-2 forms, or wage and tax statements).

• Information about any job-related health coverage available to your family.
• Proof of your expected yearly household income for the year you need this

exemption for. See page 9 for examples of documents you can send.

Why do we ask for
this information?

Get help with this
application

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.
• Online: HealthCare.gov.
• Phone: Call the Marketplace Call Center at 1-800-318-2596. TTY users should

call 1-855-889-4325.

• In person: There may be counselors in your area who can help. Visit

HealthCare.gov, or call the Marketplace Call Center at 1-800-318-2596 for
more information.

• En Español: Llame a nuestro centro de ayuda gratis al 1-800-318-2596.
• Other languages: 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.

You have the right to get the information in this product in an alternate format.
You also have the right to file a complaint if you feel you’ve been discriminated
against. Visit www.cms.gov/about-cms/agency-Information/aboutwebsite/
cmsnondiscriminationnotice.html, or call the Marketplace Call Center at
1-800-318-2596 for more information. TTY users should call 1-855-889-4325.

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.
FFM-AFFORDABILITY

Page 1 of 10

Please print in capital letters using black or dark blue ink only. Fill in the circles (

) like this

STEP 1: Tell us about yourself.
(The person who files a federal income tax return in your household should be the contact person for this application. If you’re applying for an
exemption for a child, we need an adult who claims the child on his or her federal income tax return to fill out this information even if the adult
doesn’t need the exemption.)
Do you live in Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Hawaii, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine,
Michigan, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, North Carolina, North Dakota, Ohio,
Oklahoma, Oregon, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Virginia, West Virginia, Wisconsin, or Wyoming?
YES. Fill out this application.
NO. Download the SBM-Affordability exemption application if you live in California, Colorado, the District of Columbia, Idaho,
Maryland, Massachusetts, Minnesota, New York, Rhode Island, Vermont, or Washington.
Give your legal name
1. First name

Middle name

Last name

3. Apartment or suite number

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

4. City

5. State

6. ZIP code

8. Mailing address (if different from home address)

10. City

14. Daytime phone number

Suffix

7. County, parish, or township

9. Apartment or suite number

11. State

12. ZIP code

13. County, parish, or township

15. Evening phone number

Please give us a phone number so the Marketplace can contact you if we need more information to process your application.
We won’t use your phone number for any other purpose.
16. Do you want to get information by email from the Marketplace? .......................................................................................................

Yes

Email address:
17. What’s your preferred spoken language? What’s your preferred written language?

STEP 2: Tell us about your tax household.
Who do you need to include on this application?

You need to complete Step 2 for every person in your household who is on the same federal income tax return.

For Person 1:

Person 1 must be an adult who files a federal income tax return in your household, even if they don’t want an exemption.

For Person 2:

Person 2 can be either:
• A spouse who files taxes jointly with Person 1.
• Anyone that Person 1 claims as a dependent on the same tax return.

Who not to include:

• A spouse who files taxes separately. Spouses who file separately need to fill out a separate application for themselves and for each person
they claim on their tax return.

• Anyone who lives with you but who isn’t listed on your tax return. Each person who needs an exemption must be on an application with the
person who lists them on a tax return.

If you don’t plan to file taxes, you don’t need to apply for an exemption.
You’ll get an eligibility determination letter in the mail after your application is processed. If you get this exemption, we’ll give you an Exemption
Certificate Number (ECN) with your approval letter. Keep the letter for your records. You’ll need to put this number on your federal income tax
return at the time you file taxes.
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.
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.
FFM-AFFORDABILITY

Page 2 of 10

STEP 2: PERSON 1 (Start with yourself.)
Person 1 must be the person who files the household federal income tax return, even if the person doesn’t need this exemption.
1. First name

Middle name

Last name

2. Relationship to you?

Suffix

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

4. Sex

SELF

Male

Female

5. Social Security Number (SSN)

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 help make sure that if you get an exemption, it’s applied correctly on your taxes. If someone wants help getting an SSN,
call 1-800-772-1213 or visit socialsecurity.gov. TTY users should call 1-800-325-0778.
6. List the relationship to Person1, names, DOBs, SSN, and sex of anyone that would be on your federal tax return if you were going to file one. If you need this
exemption so you can get an exemption from paying the tax penalty or catastrophic insurance, Select YES for "Want Exemption?" otherwise select NO. Only list
a spouse if you would file a joint return. Do not list a spouse if you would file married, filing separately. Select Yes if you want the exemption for yourself,
otherwise select No. If you would file a single return, skip the table after checking the box below.
a. Do you want this exemption for yourself?

NO.

YES..

(skip table if you check this box and go to Question 7.

b. I would file a federal tax return as a single individual.
Relationship to
Person 1 (required)
(for example, spouse,
son, daughter, parent)

First Name
(required)

Last Name
(required)

Date of Birth
MM/DD/YYYY
(required)

Social Security Number
###-##-####

Sex
(required)

Want exemption?
(required)

YES..

NO.

YES..

NO.

YES..

NO.

YES..

NO.

YES..

NO.

7. For what year and months do you or members of your tax household need this exemption?

Year

20 ___

Months

January

February

March

April

May

8. Are you pregnant?.......................................................................................

June
Yes

July

August

September

October

November December

a. If yes, how many babies are expected during this pregnancy?
9. Are you or another parent in your household the main caretaker of a child under the age of 19 even if he or she is claimed by
someone else on his or her tax return? (Select “yes” if you or your spouse takes care of this child.)..............................................................................

Yes

10. Within the past 6 months, have you used tobacco regularly (4 or more times per week
on average excluding religious or ceremonial uses)?...............................................................................................................................................................

Yes

11. Are you a U.S. citizen or U.S. national?
YES. If yes, skip to question 16.

NO. If no, continue to question 12.

12. Are you a naturalized or derived citizen? (This usually means you were born outside the United States)
YES. If yes, skip to question 16.

NO. If no, continue to question 13.

13. If you aren’t a U.S. citizen or U.S. national, do you have eligible immigration status?
YES. Enter document type and ID number. See instructions.
Immigration document type
Status type (optional)
Write your name as it appears on your immigration document.

Page 3 of 10

STEP 2: PERSON 1 (Continue with yourself.)
Optional:
(Fill in all
that apply.)

14. If Hispanic/Latino, ethnicity
15. Race:

White

Vietnamese

Mexican

Mexican American

Black or African American

Other Asian

Chicano/a

Puerto Rican

American Indian or Alaska Native

Native Hawaiian

Guamanian or Chamorro

Filipino

Samoan

Cuban
Japanese

Other
Korean

Other Pacific Islander

Asian Indian

Chinese

Other

Other health coverage:
16. Are you offered health coverage from a job?
Select 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.
17.

Are you enrolled in health coverage now from any of the types listed below?

COBRA, Medicaid, CHIP, Medicare, TRICARE, VA health care program, Peace Corps, Other.......................................................................................................

Yes

Current job & income information
We need to know about any income you have made or expect to make from a job, self-employment, unemployment, retirement, pensions, rental property,
fishing/farming, alimony, and Social Security (if taxable) during the year you want the exemption. Submit a support document for each type of income listed.

Job 1:
18. Do you expect any income during the year you want this exemption?
YES. If yes, answer the income questions below.
NO. If no, skip to PERSON 2 or Step 4, Signature Page.
19. Employer name (as listed on pay stub or W-2)

20. Amount (wages, tips, commissions,
bonuses, or overtime before taxes)

Hourly Average number of hours worked each week:

How often?

Monthly

Quarterly

Semi-annually

Weekly

Every 2 weeks

Twice a month

Yearly
22. When did/will this job end? (mm/dd/yyyy)

21. When did you start this job? (mm/dd/yyyy)

Fill in if this job doesn’t have an end date
23. If you don’t expect to get this income every month, write in the year and fill in the month(s) that you expect to get income from this job:

Year

Months you expect to get job #1 income

THIS YEAR

20 ___

January

February

March

April

May

June

July

August

September

October

November December

January

February

March

April

May

June

July

August

September

October

November December

NEXT YEAR

20 ___

Job 2: (If you have more than 2 jobs, make a copy of this page.)
24. Employer name (as listed on pay stub or W-2)

25. Average hours worked each WEEK

26. When did you start this job? (mm/dd/yyyy)

27. When did/will this job end? (mm/dd/yyyy)

Fill in if if this job doesn’t have an end date

Page 4 of 10

STEP 2: PERSON 1 (Continue with yourself.)
28. If you don’t expect to get this income every month, write in the year and fill in the months that you expect to get income from this job:

Year

Months you expect to get job #2 income

THIS YEAR

20 ___

January

February

March

April

May

June

July

August

September

October

November December

January

February

March

April

May

June

July

August

September

October

November December

NEXT YEAR

20 ___

YES.
29. Are you self-employed?
a. Type of work/business name:

b. Amount of net income
(profits after business
expenses are paid)
you will get from this
self-employment?

NO.

How often?

Weekly

Every 2 weeks

Twice a month

Quarterly

Semi-annually

Yearly

Monthly

$
30. When did you start this self-employment? (mm/dd/yyyy)

31. When did/will this self-employment end? (mm/dd/yyyy)

Fill in if your self-employment doesn’t have an end date
32. If you don’t expect to get self-employment income every month, write in the year and fill in the months that you expect to get this income below.
If you have more than one source of self-employment income, make a copy of this page.

Year

Months you expect to get self-employment income

THIS YEAR

20 ___

January

February

March

April

May

June

July

August

September

October

November December

January

February

March

April

May

June

July

August

September

October

November December

NEXT YEAR

20 ___

33. Other income: Tell us about other income you report on a federal income tax return. List the income type, amount (before taxes), and how often you get it.
Some common types of income are listed below. If you have additional income you report on a federal tax return, fill it in under “Other.”
NOTE: You don’t need to tell us about income that’s not reported on a tax return, like child support, veteran’s payments, or food stamps. If you get Social
Security benefits that are taxable, include the taxable amount listed on your most recent tax return. Don’t include amounts for disability benefits, survivor’s
benefits, old age benefits that aren’t taxable, or any Supplemental Security Income (SSI) benefit.
Do you expect to get taxable income from a source other than a job or self-employment?
YES. If yes, fill in the table below.
NO. If no, skip to question 35.

Page 5 of 10

STEP 2: PERSON 1 (Continue with yourself.)
Type of income

Amount

Unemployment

Retirement account
withdrawals (taxable
amounts ONLY)

Pension

Farming/fishing (net)

Rental/royalty (net)

Alimony received

Social Security (taxable
amount ONLY)

Other (write type):

How often

(Weekly, Every 2 weeks,
Twice a month, Monthly,
Quarterly, Semi-annually, Yearly)

Date started
(mm/dd/yyyy)

Date ended/
will end
(mm/dd/yyyy)

Fill in
if no
expected
end date

Number of
months you
expect to get
this income
per year

34. Deductions: If you pay for certain things that can be deducted on a federal income tax return (see IRS Form 1040, lines 23-35), fill in information about
which deductions you plan to take. Some common types of deductions are listed below. If you have additional deductions from IRS Form 1040, lines 23-35, fill
them in under “Other”.
Do you expect to to take any deductions for the year you are requesting this exemption?
YES. If yes, fill in the table below.
NO. If no, skip to next person or Step 4, signature page.

Type of deduction

Estimated yearly amount

Did you take
this deduction last year?

Alimony paid

Yes

IRA deduction

Yes

Student loan interest paid

Yes

Other (write type):

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

Page 6 of 10

a copy of Step 2: Person 2 (pages 6,7, and 8) if there are
STEP 2: PERSON 2 Make
more than 2 people in your household.
Fill out this page for a spouse who files taxes jointly with you and for anyone you claim as a dependent on your federal income tax return.
1. First name

Middle name

Last name

2. Is PERSON 2 pregnant?...............................................................................

Yes

Suffix

a. If yes, how many babies are expected during this pregnancy?
3. Are you or another parent in your household the main caretaker of a child under the age of 19 even if they are claimed by someone else
on their tax return? (Select “yes” if you or your spouse takes care of this child.).................................................................................................................

Yes

4. Within the past 6 months, has PERSON 2 used tobacco regularly (4 or more times per week)
on average excluding religious or ceremonial uses)?...............................................................................................................................................................

Yes

5. Is PERSON 2 a U.S. citizen or U.S. national?
YES. If yes, skip to question 8.

NO. If no, continue to question 6.

6. Are you a naturalized or derived citizen? (This usually means you were born outside the U.S.)
YES. If yes, skip to question 8.

NO. If no, continue to question 7.
YES. Enter document type and ID number. See instructions.

7. If PERSON 2 isn’t a U.S. citizen or U.S. national, do they have eligible immigration status?
Immigration document type

Optional:
(Fill in all
that apply.)

Status type (optional)

8. If Hispanic/Latino, ethnicity:
9. Race:

White

Vietnamese

Write PERSON 2’s name as it appears on their immigration document.

Mexican

Mexican American

Black or African American

Other Asian

Chicano/a

Puerto Rican

American Indian or Alaska Native

Native Hawaiian

Guamanian or Chamorro

Filipino

Samoan

Cuban
Japanese

Other
Korean

Other Pacific Islander

Asian Indian

Chinese

Other

Other health coverage:
10. Is PERSON 2 offered health coverage from a job?
Select 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.
11.

Are you enrolled in health coverage now from any of the types listed below?

COBRA, Medicaid, CHIP, Medicare, TRICARE, VA health care program, Peace Corps, Other.......................................................................................................

Yes

Current job & income information
We need to know about any income PERSON 2 has made or expects to make from a job, self-employment, unemployment, retirement, pensions, rental property,
fishing/farming, alimony, and Social Security (if taxable) during the year you want the exemption. Submit a support document for each type of income listed.

Job 1:
12. Do you expect any income during the year you want this exemption?
YES. If yes, answer the income questions below.
NO. If no, skip to next person or Step 4, Signature Page.
13. Employer name (as listed on paystub or W-2)

14. Amount (wages, tips,
commissions, bonuses, or overtime
before taxes)

How often?

Hourly Average number of hours worked each week:
Monthly

Quarterly

Semi-annually

Weekly

Every 2 weeks

Twice a month

Yearly

Page 7 of 10

STEP 2: PERSON 2 (Continue with PERSON 2.)
16. When did/will this job end? (mm/dd/yyyy)

15. When did you start this job? (mm/dd/yyyy)

Fill in if this job doesn’t have an end date
17. If PERSON 2 doesn’t expect to get this income every month, write in the year and fill in the months that PERSON 2 expects to get income from this job:

Year

Months PERSON 2 expects to get job #1 income

THIS YEAR

20 ___

January

February

March

April

May

June

July

August

September

October

November December

January

February

March

April

May

June

July

August

September

October

November December

NEXT YEAR

20 ___

Job 2: (If PERSON 2 has more than 2 jobs, make a copy of this page.)
18. Employer name (as listed on paystub or W-2)

20. When did PERSON 2 start this job? (mm/dd/yyyy) 21. When did/will this job end? (mm/dd/yyyy)

19. Average hours worked each WEEK

Fill in if PERSON 2 is still working at this job
22. If PERSON 2 doesn’t expect to get this income every month, write in the year and fill in the months that PERSON 2 expects to get income from this job:

Year

Months PERSON 2 expects to get job #2 income

THIS YEAR

20 ___

January

February

March

April

May

June

July

August

September

October

November December

January

February

March

April

May

June

July

August

September

October

November December

NEXT YEAR

20 ___

23. Is PERSON 2 self-employed?
a. Type of work/business name:

b. Amount of net income
(profits once business expenses
are paid) PERSON 2 will get
from this self-employment?

YES.

NO.

How often?

Weekly

Every 2 weeks

Twice a month

Quarterly

Semi-annually

Yearly

Monthly

$
24. When did PERSON 2 start this self-employment? (mm/dd/yyyy)

25. When did/will this self-employment end? (mm/dd/yyyy)

Fill in if PERSON 2’s self-employment doesn’t have an end date
26. If PERSON 2 doesn’t expect to get self-employment income every month, write in the year and fill in the months that PERSON 2 expects to get this
income below. If PERSON 2 has more than one source of self-employment income, make a copy of this page.

Year

Months PERSON 2 expects to get self-employment income

THIS YEAR

20 ___

January

February

March

April

May

June

July

August

September

October

November December

January

February

March

April

May

June

July

August

September

October

November December

NEXT YEAR

20 ___

Page 8 of 10

STEP 2: PERSON 2 (Continue with PERSON 2.)
27. Other income: Tell us about other income PERSON 2 reports on a federal income tax return. List the income type, amount (before taxes), and how often received.
Some common types of income are listed below. If PERSON 2 has additional income he/she reports on a federal tax return, fill it in under “Other”.
NOTE: You don’t need to tell us about income that’s not reported on a tax return, like child support, veteran’s payments, or food stamps. If PERSON 2 gets
Social Security benefits that are taxable, include the taxable amount listed on his/her most recent tax return. Don’t include amounts for disability benefits,
survivor’s benefits, old age benefits that aren’t taxable, or any Supplemental Security Income (SSI) benefit.
Do you expect to get taxable income from a source other than a job or self-employment?
YES. If yes, fill in the table below.
NO. If no, skip to question 28.

Type of income

Amount

Unemployment

Retirement account
withdrawals (taxable
amounts ONLY)

Pension

Farming/fishing (net)

Rental/royalty (net)

Alimony received

Social Security (taxable
amount ONLY)

Other (write type):

How often

(Weekly, Every 2 weeks,
Twice a month, Monthly,
Quarterly, Semi-annually, Yearly)

Date started
(mm/dd/yyyy)

Date ended/
will end
(mm/dd/yyyy)

Fill in
if no
expected
end date

Number of
months you
expect to get
this income
per year

28. Deductions: If PERSON 2 pays for certain things that can be deducted on a federal income tax return (see IRS Form 1040, lines 23-35), fill in information
about which deductions he/she plans to take. Some common types of deductions are listed below. If PERSON 2 has additional deductions from IRS Form 1040,
lines 23-35, fill them in under “Other”.
Do you expect to to take any deductions for the year you are requesting this exemption?
YES. If yes, fill in the table below.
NO. If no, skip to next person or Step 4, signature page.

Type of deduction

Estimated yearly amount

Did PERSON 2 take
this deduction last year?

Alimony paid

Yes

IRA deduction

Yes

Student loan interest paid

Yes

Other (write type):

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

Page 9 of 10

STEP 3: Proof of yearly income
You MUST submit proof of each type of income you listed for each person on this application. We can’t approve your exemption without
proof of income. The table below lists possible documents for each type of income; you may submit other documents not on the list if they
are included in the income amount you listed on your application.
If you expect your income to increase or decrease during the year you are requesting this exemption, 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 selfemployment ledger that includes your expected income.

Income Type

Documents

All income types

• A copy of your most recent federal income tax return, Form 1040, if your income and/or deductions listed
on this application are similar to your last tax return. Send official documents only — handwritten 1099s
and W-2s are not acceptable.

Job

• One or more pay stubs that show the typical pay and hours you work at the job. The pay stubs should
show the gross amount and any tips, commissions, bonuses, or overtime pay.

• Wages and tax statement (W-2) from the most recent year
• 1099-MISC (Non-employee compensation)
Net self-employment

• Self-employment ledger
• Schedule C
• Form 1120S
• Other recent tax document showing self-employment
• Copy of a check paid for the self-employment services

Other Income

Documents

Unemployment

• Letter from government agency for unemployment benefits. If the document doesn’t list the start and
end dates, write your best guess at when the benefit will end on the document.

Retirement
(taxable amounts ONLY)

• 1099 or relevant tax document that lists any withdrawal amounts

Pension

• Pension letter

• Documents showing taxable amount from account withdrawals
• 1099 or relevant tax document

Rental/royalties (net)

• Lease agreement for land or property you own with lease amount/frequency
• Document showing royalty income
• 1099-MISC (royalty/rental income fields)

Alimony paid/received

• Court order or legal document showing the monthly alimony amount and the start and end dates (if
applicable)

Farming/fishing (net)

• Schedule C
• Schedule F
• 1099-G

Social Security
(taxable amounts ONLY)

• Copy of most recent Form 1040 that shows the taxable amount in line 20b. Don’t send copies of your
benefit or COLA letter UNLESS the taxable amount is listed on it.

Page 10 of 10

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 hhs.gov/ocr/office/file.
Is anyone applying for an exemption on this application incarcerated (detained or jailed)? ........................................................

Yes

If yes, tell us the person’s name. The name of the incarcerated person is:
Fill in here if this person is facing
disposition of charges.
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), Social Security, the Department of Homeland Security, 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 exemption 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 may have a relative, friend, legal counsel, or another spokesperson, including an Authorized Representative, help you make an appeal
request or participate in your appeal. This is optional.

• The outcome of an appeal could change the eligibility of other members of your tax household.
To appeal your exemption application results, visit HealthCare.gov/marketplace-appeals/. Or call the Marketplace Call Center at
1-800-318-2596. TTY users should call 1-855-889-4325.
PERSON 1 should sign this application. If you’re an authorized representative, you may sign here as long as PERSON 1 signed Appendix C.
The person who signs this application must be the person who files a federal income tax return and must be an adult over the age of 18.
Signature

Date signed (mm/dd/yyyy)

STEP 5: Mail completed application

✉

Mail your signed application and documents showing your yearly income (see examples on page 10) to:

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

What happens next?
Send your complete, signed application with required documents to the address above. We’ll follow up with you within
1–2 weeks. You may receive a call from the Marketplace if we need more information. You’ll get an eligibility determination
letter in the mail after we process your exemption application. If you qualify for this exemption, we’ll give you an Exemption
Certificate Number (ECN) that you’ll put on your federal income tax return. If you don’t hear from us, call the Health Insurance
Marketplace Help Center at 1-800-318-2596. TTY users should call 1-855-889-4325.

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 0938-1190. 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.

Appendix A (Exemptions)

DRAFT MOCKUP
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, even if he or she
doesn't accept the coverage. Attach a copy of this page for each job that offers coverage.

Tell us about the job that offers coverage.

Make a copy of this page and take it to the employer who offers coverage to help you answer these questions.

EMPLOYEE INFORMATION
1. Employee name (First, Middle, Last)

2. Employee Social Security Number

–

EMPLOYER INFORMATION
3. Employer name

4. Is the employee currently eligible for coverage offered by this employer, or will the employee become eligible in the next 3 months?....................

Yes

5. Does the employer offer a health plan that meets the minimum value standard*? .....................................................................................................

Yes

If you answered No to question 4 and/or question 5 and you are applying for an SBM-affordability exemption, you do not need to fill out the
remaining questions, but you need to apply for coverage on your state’s Marketplace website and provide the LCBP and APTC amounts for each member
of your tax household. See page 4 of the SBM-affordability exemption for more information.
If you answered No to question 4 and/or question 5 and you are applying for an FFM-affordability exemption, you do not need to fill out the
remaining questions.
6. List the first and last names of anyone else in your tax household who is eligible for coverage from this job.
Name

Name

Tell us about the lowest-cost health plan offered by this employer.
7. 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 he or she received the maximum discount for any tobacco cessation programs,
and didn’t receive any other discounts based on wellness 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

8. For the lowest-cost plan that meets the minimum value standard* offered to the employee and family members in your tax household. If the
employer has wellness programs, provide the premium that the employee would pay if he or she doesn'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

*A health plan meets the minimum value standard if it pays at least 60 percent of the total cost of medical services for a standard population and offers substantial coverage of
hospital and doctor services. Most job-based plans meet the minimum value standard.

DRAFT MOCKUP
OMB No. 0938-1191

Appendix C
Assistance with completing this application
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

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 or remove 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

4. City

3. Apartment or suite number

5. State

6. ZIP code

7. Phone number

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. Signature of PERSON 1 listed on this application

11. Date signed (mm/dd/yyyy)

File Type	application/pdf
File Title	Exemption Federally Facilitated Marketplace
Subject	Application for Exemption from the Shared Responsibility Payment for Individuals who are Unable to Afford Coverage, and are in a
Author	CMS
File Modified	2016-12-21
File Created	2016-10-27