CMS-10466 Application for Exemptions Religious Sects or Divis

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

CMS-10466 - Appendix A - Religious-Sect-Exemption-Application

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⚠️ Notice: This form may be outdated.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:

2024-03-14 - Revision of a currently approved collection

Document [pdf]

Download: pdf | pdf

Application for exemption from the Shared Responsibility
Payment for members of recognized religious sects or divisions
Use this application
to apply for an
exemption from the
Shared

OMB Control Number 0938-1190
Expiration Date: XX/XXXX

• 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 the payment. This application is for an exemption
for members of recognized religious sects or divisions. You may apply for other
exemptions when you file your federal income tax return.
• You don’t need 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.

Responsibility
Payment
Who can use this
application?

What you need to
apply

Why do we ask for
this information?
Get help with 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 Social Security benefits as 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").
• You can use one application for multiple people in your tax household.
• If you’re over 21 and qualify for this exemption, you’ll receive a lifetime exemption. This
means you won’t need to reapply for this exemption. If your membership with your
religious sect ends you’ll need to make the Shared Responsibility Payment or have another
exemption.
• If you’re under 21 and qualify for this exemption, you’ll need to apply for this exemption
yourself when you turn 21.
• If you have a religious sect or division exemption and you either get married or have a child,
you’ll need to apply for the exemption again with your spouse and/or child. All people in
your tax household require their own Exemption Certificate Number (ECN).
•
•
•
•

The name and address of your approved religious sect or division.
Date of birth for all household members 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.

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 trained assisters in your area who can help. Visit
localhelp.healthcare.gov, or call the Marketplace Call Center.
• 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.
We’ll provide free help in your language.

NEED HELP WITH YOUR APPLICATION? Visit Healthcare.gov/exemptions, or call 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. We’ll provide free help in your language. TTY: 1-855-889-4325

RELIGIOUS SECT/DIVISIONS 1.02

Page 1 of 5

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, and is known as "Person 1." If you're applying for an exemption for a child, an adult who claims the
child on his or her federal income tax return should fill out and sign this application, even if the adult doesn't need
the exemption.

Use your legal name
1. First name

Middle name

Last name

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

3. Apartment or suite number

4. City

5. State

8. Mailing address

Suffix

6. ZIP code

7. County, parish, or township

(Select if same as home address)

10. City

9. Apartment or suite number
11. State

12. ZIP code

13. 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 (###-###-####)

Best time to call:
Afternoon
Morning
Evening

17. If Hispanic/Latino, ethnicity:

(Select all that
18. Race:
apply.)

White

Other Asian

Weekend

16b. What is your preferred written language?

Mexican

Black or African American

Vietnamese

Best time to call:
Afternoon
Morning
Evening

Weekend

16a. What is your preferred spoken language?

Optional:

15. Other phone number (###-###-####)

Mexican American

Puerto Rican

American Indian or Alaska Native

Native Hawaiian

Guamanian or Chamorro

Chicano/a

Filipino

Japanese

Samoan

Cuban

Other

Korean

Asian Indian

Other Pacific Islander

Chinese

Other

STEP 2: Tell us about your tax household
Who to include on this application:
• The adult who files the federal income tax return for this household – list this person, who will be known as "Person 1", on the first line of the
table on the next page.
• A spouse who’s filing taxes jointly with you.
• Anybody Person 1 claims as a dependent on the federal income tax return.
You should apply for this exemption based on how you file taxes, with the following exception: If you’re 21 or older and included as a dependent
on someone else’s tax return, submit your own exemption application.

Who NOT to include on your application:

• A spouse who files taxes separately from you. Spouses who file separately must fill out a separate exemption application for themselves and
include every person they claim on their tax return.
• Anyone who lives with you but isn’t (or won’t be) listed on your tax return for the year(s) you want this exemption.
If you don’t plan to file taxes, you don’t need to apply for an exemption.

RELIGIOUS SECT/DIVISIONS 1.02

Page 2 of 5

STEP 2: Tell us about your tax household (continued)
The person in line 1 below, who will be known as "Person 1," must be the person who files a federal
income tax return for the household, even if the person doesn’t need an exemption.
For each person included on the federal income tax return, select their relationship to Person 1, the
name, date of birth, SSN, sex, and whether they want an exemption.
You must give your Social Security number (SSN) if you have one. In the table below include the
SSN for anyone requesting the exemption who has an SSN. An SSN is not necessary to qualify for the
exemption. We use SSNs to match exemptions with the right tax returns. For help getting an SSN,
visit socialsecurity.gov or call 1-800-772-1213. (TTY: 1-800-325-0778).

Relationship
to Person 1
(spouse or
dependent)

Self

First name

Last name

Date of birth

(mm/dd/yyyy)

Social Security
number
(###-##-####)

Sex

Want
exemption?

2. Do you or other members of your tax household 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 a copy of the approved form when you submit this application.
NO.
3. Are you or others in your tax household a member of an approved religious sect or division (as described in section 1402(g)(1) of the Internal
Revenue Code)?
YES. If yes, go to question 4.
NO. If no, you’re not eligible for this exemption and shouldn't complete this application. To see other categories of exemptions you may be
eligible for, visit HealthCare.gov/exemptions or call the Marketplace at 1-800-318-2596. (TTY: 1-855-889-4325)

RELIGIOUS SECT/DIVISIONS 1.02

Page 3A of 5

STEP 3: Tell us about your religious sect or division
4a. Enter your approved religious sect or division name and the date you became a member.
Full name of religious sect or division
District or congregation
Address
City

State

ZIP code

Select the name of each individual who’s a member of this religious sect or division.

RELIGIOUS SECT/DIVISIONS 1.02

Page 4 of 5

STEP 4: Read, print & sign this application
You won’t be able to print and sign your application until you’ve filled out all required information. We can’t process
unsigned applications or accept digital signatures.
I agree that:
• 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 1, known as "Person 1," should sign this application. The person who signs must be an adult over the age of 18 who files
the federal income tax return for the household. If you’re an Authorized Representative, you may sign here as long as Person 1 fills out and signs
the "Help with this application" form on page 5 of this application.

Print out application and have Person 1 sign.

Date signed (mm/dd/yyyy)

STEP 5: Mail completed application and documents
Note: A page that lists the documents you need to submit will print at the end of this application.

Mail your signed application and copies (do not send originals) of the documents listed on the page that will print at the end of this
application to:
Health Insurance Marketplace
Attn: Exemption Processing
465 Industrial Blvd.
London, KY 40741

What happens next?

We’ll call you if we need more information. If we don’t reach you by phone, we’ll send a letter. You’ll get a letter in the mail after
we’ve processed your application.
• If your application is approved, we’ll send an Exemption Certificate Number (ECN) for each approved member of your tax
household to use on your federal income tax return for the year members of your tax household didn’t have coverage. You’ll
provide the ECN when you file your return for the year your exemption has been approved.
• If you or other members of your tax household don’t qualify for the exemption, the letter will explain why.
• If you don’t hear from us within 30 days, contact the Marketplace at 1-800-318-2596. (TTY: 1-855-889-4325)

What if I think the results of my exemption application are wrong?
You can appeal. Important information about an appeal:
• The Health Insurance Marketplace must receive your appeal request within 90 days of the date of the application results notice.
• You may have a relative, friend, legal counsel, or another spokesperson, including an Authorized Representative, help you appeal
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: 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.
NEED HELP WITH YOUR APPLICATION? Visit Healthcare.gov/exemptions, or call 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. We’ll provide free help in your language. TTY: 1-855-889-4325

RELIGIOUS SECT/DIVISIONS 1.02

Page 5 of 5

Help with this application

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 the 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

Last name

Suffix

3. Apartment or suite number

2. Address

5. State

4. City

6. ZIP code

7. Phone number (###-###-####)

8. Organization name (if applicable)

9. ID number (if applicable)

By signing in block #10 below, you allow the person on this form to sign your application, get official information about this application, and act
for you on all future matters related to this application. The person who signs this form, in block #10 below, must be an adult over the age of 18
who files the federal income tax return for the household.
11. Date signed (mm/dd/yyyy)

10. Signature of tax filer

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.
1. Application start date (mm/dd/yyyy)

2. First name

Middle name

Last name

Suffix

3. Organization name (if applicable)

4. ID number (if applicable)

5. Agents/Brokers only: NPN number

RELIGIOUS SECT/DIVISIONS 1.02

File Type	application/pdf
File Title	Health Insurance Marketplace - Application for Exemption from the Shared Responsibility Payment for Individuals who Experienced
Subject	Health Insurance Marketplace, Application for Exemption, Shared Responsibility Payment for Individuals, Experienced Hardships
Author	Health Insurance Marketplace
File Modified	2019-10-02
File Created	2019-09-17