CMS-10466 Application for Exemptions Religious Sects or Divis

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

CMS-10466 - religious-sect-exemption-FINAL(ADOBE)

Exemption Applications - Eligibility for Exemptions

OMB: 0938-1190

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Application for Exemption from the Shared Responsibility
Payment for Members of Recognized Religious Sects or Divisions

DRAFT MOCKUP
OMB No. 0938-1190

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

• Every person needs to have health coverage or make a payment on their federal
income tax return called the “shared responsibility payment.”

Who can use this
application?

• Use this application if you and/or anyone in your tax household is a member of an
approved religious sect or division which is against accepting public benefits
including Medicare and SSA and described in section 1402(g)(1) of the Internal
Revenue Code, or if you have an approved and signed IRS Form 4029 (“Application
for Exemption from Social Security and Medicare Taxes and Waiver of Benefits”). If
you are opposed to the Affordable Care Act and are not a member of an approved
religious sect, please visit https://marketplace.cms.gov/applications-and-forms/
exemption-applications.html .

• Some people are exempt from making this payment. This application is for one
category of exemption, for members of Recognized Religious Sects or Divisions.
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.

• You can use one single application to ask for this exemption for more than one
person in your tax household.
• If you are over 21 and you qualify for this exemption, you will receive a lifetime
exemption. This means you won’t need to reapply for this exemption unless your
membership with your religious sect ends.
• If you are under 21 and you qualify for this exemption, you’ll need to send in your
own religious exemption application when you turn 21 to qualify for the lifetime
exemption.
• If you already have a religious sect or division exemption and you either get married or
have a child, you’ll need to send in a new application with your spouse and/or child because
each individual in your tax household requires an individual Exemption Certificate Number
(ECN).

What you
need to apply

• The name and address of your approved religious sect or division.
• Date of birth for all members of your household on this application.
• Social Security Numbers (SSNs), if you have them.
• If you have one, a copy of an approved IRS Form 4029 (“Application for Exemption
from Social Security and Medicare Taxes and Waiver of Benefits”) with required
signatures. Note: you’re not required to have this form to apply for this exemption,
as long as your religious sect or division is on the official list maintained by the Social
Security Administration.

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 ask for the name of your religious
sect or division to make sure it is on the official list maintained by the Social Security
Administration. 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.

Get help with this
application

• Online: HealthCare.gov/exemptions.
• 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.

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.
RELIGIOUS SECTS/DIVISIONS

Page 1 of 4

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.)
Give your legal name
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, parish, or township

8. Mailing address (if different from home address)

10. City

11. State

14. Daytime phone number

(

9. Apartment or suite number

)

–

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 include every person in your household who is on the same federal income 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 and isn’t listed on your tax return. Each person who needs an exemption must be on an application with the
person who lists him or her 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.
You should apply for this exemption based on how you file taxes. If you’re a member of a religious sect or division who recently turned 21, you
should submit your own exemption application to qualify for the lifetime exemption.

Page 2 of 4

STEP 2: Tell us about your tax household. (continued)
Person 1 must be the person who files a 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)

SELF
5. Social Security Number (SSN)

/
–

4. Sex
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 since 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?

YES..

NO.
(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
###-##-####

Want exemption?
(required)

Sex

YES

8. Do you have an approved IRS Form 4029 (“Application for Exemption from Social Security and Medicare Taxes and Waiver of Benefits”)
with required signatures?
YES. If yes, attach the approved copy and continue to question 12.
NO. If no, continue to question 8.
9. Are you a member of an approved religious sect or division (as described in section 1402(g)(1) of the Internal Revenue Code)?
YES. If yes, fill out questions 9-11 before continuing to question 12.
NO. If no, you will not be eligible for this exemption application. This application is for one category of exemptions, for members of Recognized
Religious Sects or Divisions. To see other categories of exemptions you may be eligible for, please visit HealthCare.gov/exemptions or call the
Marketplace at 1-800-318-2596 (TTY: 1-855-889-4325).

Page 3 of 4

STEP 2: Tell us about your tax household. (continued)
10. Enter your approved religious sect or division name. Complete all sections.
Full name of religious sect or division

District or congregation

Address

City

State

ZIP code

County, parish, or township

11. When did you become a member of this religious sect or division? (mm/yyyy)

/
12. If you’re not currently a member of this religious sect or division, tell us when you ended your membership? (mm/yyyy)

/
Enter the names of all individuals in your tax household who are a member of the same religious sect or division.

13. Are other individuals in your tax household members of a different religious sect or division (as described in section 1402(g)(1) of the Internal
Revenue Code)?
YES. If yes, fill out questions 14 - 16.
NO. If no, skip to Step 3, Read & sign this application.
14. Enter your approved religious sect or division name. Complete all sections.
Full name of religious sect or division

District or congregation

Address
City

State

ZIP code

County, parish, or township

15. When did you or other individuals in your tax household become member(s) of this religious sect or division? (mm/yyyy)

/
16. If you’re not currently a member of this religious sect or division, tell us when you ended your membership? (mm/yyyy)

/
Enter the names of all individuals in your tax household who are a member of the same religious sect or division.

Optional:
(Fill in all
that apply.)

17. If Hispanic/Latino, ethnicity:
18. Race:

White

Vietnamese

Mexican

Mexican American

Black or African American

Other Asian

Native Hawaiian

Chicano/a

Puerto Rican

American Indian or Alaska Native
Guamanian or Chamorro

Filipino

Samoan

Cuban
Japanese

Other
Korean

Other Pacific Islander

Asian Indian

Chinese

Other

Page 4 of 4

STEP 3: Read & sign this application
• I’m signing this application under penalty of perjury, which means I’ve provided 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 intentionally
provide false 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.

The person on line one 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.
Signature

Date signed (mm/dd/yyyy)

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.

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

3. Apartment or suite number

4. City

7. Phone number

(

5. State

)

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. Signature of PERSON 1 listed on this application

11. Date signed (mm/dd/yyyy)

File Type	application/pdf
File Title	Application for Exemption from the Shared Responsibility Payment for Members of Recognized Religious Sects or Divisions
File Modified	2016-12-21
File Created	2014-11-18