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pdfHealth Insurance Marke1place
Application for exemption from the Shared Responsibility
Payment for individuals who experience hardships
,j1use this
application to
apply for a
hardship
exemption from
the Shared
Responsibility
Payment
Expiration Date
xx/xx/xxxx
DRAFT MOCKUP
OM B No. 0938-1190
• Every person needs to have health coverage or make a payment on their
federal income tax return called the "Shared Responsibility Payment."
• Some people are exempt from making this payment. This application is
for one category of exemption. You may apply for 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 planning to file a
tax return. If you're not sure if you'll file, you may want to apply for an
exemption anyway.
� Who can use this · Use this application if you or anyone in your tax household
experiences a hardship that keeps you from getting
� application?
health coverage. See page 1 for the list of hardships.
• You can use one application for multiple people in your tax household.
• If you get a hardship exemption, you may qualify to enroll in a
catastrophic plan, which offers minimal coverage at a lower cost.
• What you need
to apply
0
• Documents that support your claim of hardship. See page 1 for a list of
documents needed for each hardship exemption. The document must:
1) Support the reason you're requesting an exemption, AND
2) Include dates showing when you experienced the hardship.
If you can't provide the required documents, call the Health Insurance
Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325).
Why do we ask
for this
information?
Q Get help with
this application
We ask for Social Security numbers and other information to make sure
your exemption information is sent to the Internal Revenue Service (IRS)
to match your tax return. We'll keep all the information private and
secure, as required by law. To view the Privacy Act Statement, go to
HealthCare.gov/privacy.
• Online: HealthCare.gov/exemptions
• Phone: Call the Marketplace Call Center at 1-800-318-2596 (TTY:
1-855-889-4325).
• In person: There may be counselors in your area who can help. Visit
localhelp.healthcare.gov, or call the Marketplace Call Center for more
information.
• En Espanol: 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 provide help at no cost to you.
ft NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov/exemptions or call us at 1-800-318-2596. Para obtener una copia de este formulario en Espanol, 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.
V
HARDSHIP
Page 1 of 6
Required documentation
Shut off notice from an electric, water, or gas utility
company that states service has been or will be
shut-off. Must be within the last three years.
Health Insurance Marketplace notice of appeals
decision that states that your appeal was granted or
approved.
None
NO LONGER AVAILABLE
Page 2 of 6
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.
Use your legal name
Middle name
1. First name
Last name
2. Home address (Leave blank ifyou don't have one.)
C
6. ZIP code
I I I I I I I I
(Select if same as home address)
10. City
3. Apartment or suite number
5. State
4. City
8. Mailing address
Suffix
111. State
112. ZIP code
I I I I I I I I I
7. County, parish, or township
9. Apartment or suite number
113. County, parish, or township
Please provide a phone number so we can contact you if necessary. We won't use your number for anything else.
14. Phone number
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(I I I I) I I I .I- I�- -��-��-I �O
15. Other phone number
Best Time to call:
n
::�k:::
Best Time to Call:
After noo n
Mor ni ng
Eve ni ng
D
D Weeke d
16. Do you want to get information by email from the Marketplace?............................................................................................................. (' Yes
n
(' No
Email address:
17A. What's your preferred spoken language?
178. What's your preferred written language?
STEP 2: Tell us about your tax household
Who to include in your application
• The person in line one must be the adult who files a federal income tax return for this household.
• A spouse who's filing taxes jointly with you.
• Anyone that they person in line one claims as a dependent on his or her federal income tax return.
Note: If you don't plan to file a federal income tax return, you don't need to fill out this application because you won't have to make the Shared
Responsibility Payment.
Who NOT to include in your application
• A spouse who files taxes separately. They should fill out their own exemption application and include on their own application anyone
the spouse claims as a dependent on their federal income tax return.
• Anyone who lives with you but isn't a dependent on your federal income tax return.
ft NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov, or call us at 1-800-313-2596. Para obte ner u na copia de este formulario e n Espanol, I lame 1-800-318-2596. If you need help i n a
V la nguage other than English, call 1-800-318-2596 a n d tell the customer service represe n tative the la n guage you need. We'll get you help at n o cost to you. TTY users should call 1-855-889-4325.
HARDSHIP
Page 3 of 6
STEP 2: Tell us about your tax household (start with yourself)
The person in line 1 must be the person who files a federal income tax return, even if the person doesn’t need this exemption.
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?
YES..
b. I would file a federal tax return as a single individual.
Relationship to
Person 1 (required)
(spouse or dependent)
First Name
(required)
Last Name
(required)
NO.
(skip table if you check this box and go to Question 7.
Date of Birth
MM/DD/YYYY
(required)
Social Security Number
###-##-####
Want exemption?
(required)
Sex
M
F
YES
NO
M
F
YES
NO
M
F
YES
NO
M
F
YES
NO
M
F
YES
NO
M
F
YES
NO
7. Select the type of hardship(s) you're applying for below. Note the date the hardship started, when it will end, or if it's ongoing. You need only
one exemption for any given period. You may apply for more than one hardship if the hardship events were at different times during the year.If
you're applying for more than one hardship, you must sumbit documentation for EACH hardship that requires documentation.
(Note: If your hardship started before
01/01/2014, list the first date you did
not have required health coverage.
Your hardship cannot start on a date
in the future.)
2 0
List the first and last names of each member of your tax household who has this hardship reason.
2 0
List the first and last names of each member of your tax household who has this hardship reason.
2 0
List the first and last names of each member of your tax household who has this hardship reason.
2 0
List the first and last names of each member of your tax household who has this hardship reason.
Page 4 of 6
STEP 2: Tell us about your tax household (continued)
(Note: If your hardship started before
01/01/2014, list the first date you did
not have required health coverage.
You hardship cannot start on a date in
the future.)
2 0
List the first and last names of each member of your tax household who has this hardship reason.
2 0
List the first and last names of each member of your tax household who has this hardship reason.
2 0
List the first and last names of each member of your tax household who has this hardship reason.
2 0
List the first and last names of each member of your tax household who has this hardship reason.
2 0
List the first and last names of each member of your tax household who has this hardship reason.
2 0
List the first and last names of each member of your tax household who has this hardship reason.
2 0
List the first and last names of each member of your tax household who has this hardship reason.
2 0
List the first and last names of each member of your tax household who has this hardship reason.
2 NGER
0
---------- NO LO
AVAILABLE ---------2 0
List the first and last names of each member of your tax household who has this hardship reason.
(Explain how this hardship prevented you from getting health insurance):
8. If Hispanic/Latino, ethnicity:
9. Race:
Page 5 of 6
The person on line 1 should be the one to sign this application.
an Authorized Representative, you may sign here as long as the person on line one signed Appendix C.
Print out application and sign
Date signed (mm/dd/yyyy)
/
/
Page 6 of 6
AppendixC
Form Approved
0MB No. 0938-1191
Assistance with this application
For certified application counselors, navigators, agents, and brokers only
Complete this section only if you're a certified application counselor, navigator, agent, or broker
filling out this application for somebody else.
I
1. Application start date (mm/dd/yyyy)
I I II I II I I I
2. First name
Middle name
Suffix
Last name
3. Organization name
4. ID number (if applicable)
5. Agents/Brokers only: NPN number
I
I
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. First name
Middle name
Suffix
Last name
3. Apartment or suite number
2. Address
5. State
4. City
6. ZIP code
I
7. Phone number
| File Type | application/pdf |
| File Title | Exemption State Based Marketplace |
| Subject | Application for Exemption from the Shared Responsibility Payment for Individuals who are Unable to Afford Coverage and are in Ce |
| Author | CMS |
| File Modified | 2016-12-21 |
| File Created | 2016-10-27 |