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Form 1095-A (2024) Page 2
Part II. Covered Individuals, lines 16–20. Part II reports information
Instructions for Recipient about each individual who is covered under your policy. This information
You received this Form 1095-A because you or a family member includes the name, SSN, date of birth, and the starting and ending dates
enrolled in health insurance coverage through the Health Insurance of coverage for each covered individual. For each line, a date of birth is
Marketplace. This Form 1095-A provides information you need to reported in column C only if an SSN isn’t entered in column B.
complete Form 8962, Premium Tax Credit (PTC). You must complete If advance credit payments are made, the only individuals listed on
Form 8962 and file it with your tax return (Form 1040, Form Form 1095-A will be those whom you certified to the Marketplace would
1040-SR, or Form 1040-NR) if any amount other than zero is shown be in your tax family for the year of coverage (yourself, spouse, and
in Part III, column C, of this Form 1095-A (meaning that you dependents). If you certified to the Marketplace at enrollment that one or
received premium assistance through advance payments of the more of the individuals who enrolled in the plan aren’t individuals who
premium tax credit (also called advance credit payments)) or if you would be in your tax family for the year of coverage, those individuals
want to take the premium tax credit. The filing requirement applies won’t be listed on your Form 1095-A. For example, if you indicated to
whether or not you’re otherwise required to file a tax return. If you are the Marketplace at enrollment that an individual enrolling in the policy is
filing Form 8962, you cannot file Form 1040-NR-EZ, Form your adult child who will not be your dependent for the year of coverage,
1040-SS, or Form 1040-PR. The Marketplace has also reported the that child will receive a separate Form 1095-A and won’t be listed in
information on this form to the IRS. If you or your family members Part II on your Form 1095-A.
enrolled at the Marketplace in more than one qualified health plan
policy, you will receive a Form 1095-A for each policy. Check the If advance credit payments are made and you certify that one or more
information on this form carefully. If you think the information is enrolled individuals aren’t individuals who would be in your tax family for
incorrect, or if you think you should not have received a Form 1095-A the year of coverage, your Form 1095-A will include coverage
because neither you nor anyone else in your family was enrolled in information in Part III that is applicable solely to the individuals listed on
Marketplace health insurance, please contact your Marketplace Call your Form 1095-A, and separately issued Forms 1095-A will include
Center. If you purchased insurance through the Federally-facilitated coverage information, including dollar amounts, applicable to those
Marketplace, you can find your Call Center information at individuals not in your tax family.
www.healthcare.gov/contact-us/. If you purchased insurance through a If advance credit payments weren’t made and you didn’t identify at
State-based Marketplace, you can find your Call Center information on enrollment the individuals who would be in your tax family for the year of
your State-based Marketplace website. You can find a list of State- coverage, Form 1095-A will list all enrolled individuals in Part II on your
based Marketplace websites at www.healthcare.gov/marketplace-in- Form 1095-A.
your-state/. If you or your family members were enrolled in a If there are more than five individuals covered by a policy, you will
Marketplace catastrophic health plan or separate dental policy, you receive one or more additional Forms 1095-A that continue Part II.
aren’t entitled to take a premium tax credit for this coverage when you
file your return, even if you received a Form 1095-A for this coverage. Part III. Coverage Information, lines 21–33. Part III reports information
For additional information related to Form 1095-A, go to www.irs.gov/ about your insurance coverage that you will need to complete Form
Affordable-Care-Act/Individuals-and-Families/Health-Insurance- 8962 to reconcile advance credit payments or to take the premium tax
Marketplace-Statements. credit when you file your return.
Additional information. For additional information about the tax Column A. This column is the monthly premiums for the plan in which
provisions of the Affordable Care Act (ACA), including the premium tax you or family members were enrolled, including premiums that you paid
credit, see www.irs.gov/Affordable-Care-Act/Individuals-and-Families or and premiums that were paid through advance payments of the
call the IRS Healthcare Hotline for ACA questions (800-919-0452). premium tax credit. If you or a family member enrolled in a separate
dental plan with pediatric benefits, this column includes the portion of
VOID box. If the “VOID” box is checked at the top of the form, you the dental plan premiums for the pediatric benefits. If your plan covered
previously received a Form 1095-A for the policy described in Part I. benefits that aren’t essential health benefits, such as adult dental or
That Form 1095-A was sent in error. You shouldn’t have received a vision benefits, the amount in this column will be reduced by the
Form 1095-A for this policy. Don’t use the information on this or the premiums for the nonessential benefits. If the policy was terminated by
previously received Form 1095-A to figure your premium tax credit on your insurance company due to nonpayment of premiums for 1 or more
Form 8962. months, then a -0- may appear in this column for these months
CORRECTED box. If the “CORRECTED” box is checked at the top of regardless of whether advance credit payments were made for these
the form, use the information on this Form 1095-A to figure the premium months. See the instructions for Form 8962, Part II, on how to complete
tax credit and reconcile any advance credit payments on Form 8962. Form 8962 if -0- is reported for 1 or more months.
Don’t use the information on the original Form 1095-A you received for Column B. This column is the monthly premium for the second lowest
this policy. cost silver plan (SLCSP) that the Marketplace has determined applies to
Part I. Recipient Information, lines 1–15. Part I reports information members of your family enrolled in the coverage. The applicable SLCSP
about you, the insurance company that issued your policy, and the premium is used to compute your monthly advance credit payments
Marketplace where you enrolled in the coverage. and the premium tax credit you take on your return. See the instructions
Line 1. This line identifies the state where you enrolled in coverage for Form 8962, Part II, on how to use the information in this column or
through the Marketplace. how to complete Form 8962 if there is no information entered, the
information is incorrect, or the information is reported as -0-. If the
Line 2. This line is the policy number assigned by the Marketplace to policy was terminated by your insurance company due to nonpayment
identify the policy in which you enrolled. If you are completing Part IV of of premiums for 1 or more months, then a -0- may appear in this column
Form 8962, enter this number on line 30, 31, 32, or 33, box a. for the months, regardless of whether advance credit payments were
Line 3. This is the name of the insurance company that issued your made for these months.
policy. Column C. This column is the monthly amount of advance credit
Line 4. You are the recipient because you are the person the payments that were made to your insurance company on your behalf to
Marketplace identified at enrollment who is expected to file a tax return pay for all or part of the premiums for your coverage. If this is the only
and who, if qualified, would take the premium tax credit for the year of column in Part III that is filled in with an amount other than zero for a
coverage. month, it means your policy was terminated by your insurance company
Line 5. This is your social security number (SSN). For your protection, due to nonpayment of premiums, and you aren’t entitled to take the
this form may show only the last four digits. However, the Marketplace premium tax credit for that month when you file your tax return. You
has reported your complete SSN to the IRS. must still reconcile the entire advance payment that was paid on your
behalf for that month using Form 8962. No information will be entered in
Line 6. A date of birth will be entered if there is no SSN on line 5. this column if no advance credit payments were made.
Lines 7, 8, and 9. Information about your spouse will be entered only if Lines 21–33. The Marketplace will report the amounts in columns A, B,
advance credit payments were made for your coverage. The date of and C on lines 21–32 for each month and enter the totals on line 33. Use
birth will be entered on line 9 only if line 8 is blank. this information to complete Form 8962, line 11 or lines 12–23.
Lines 10 and 11. These are the starting and ending dates of the policy.
Lines 12 through 15. Your address is entered on these lines.
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