State of Rhode Island Division of Taxation 
           Form IND-HEALTH 
           Individual Health Insurance Mandate Form                             23106299990101

     Name                                                               Social security number

                                        Coverage Exemption Reasons and Codes
                                                                            Aggregate Self Only Coverage                            G1
                    Income Below Filing Threshold           NC              Considered Unaffordable
                                                                            Member of Tax Household Born 
           Coverage Considered Unaffordable                     A           or Adopted During the Year                              H1
                      Short Coverage Gap                        B   Member of Tax Household Died During the Year                    H2
           Citizens Living Abroad & Certain Noncitizens         C           Nonresident of Rhode Island                             N
           Members of Healthcare Sharing Ministry               D       Had Minimum Essential Health Coverage                       X
                    Members of Indian Tribes                    E           HealthSource RI Exemption                               RI
                            Incarceration                       F               Medicaid                                            M
    Enter the name and social security number for each member of your tax household. For each household member, use the chart above to enter 
    an exemption code for each corresponding month in which the household member had minimum essential health coverage or an exemption. If 
    an individual qualified for an exemption through HealthSource RI, enter the exemption number(s) in the space provided.  
     
    Refer to the Individual Mandate Instructions for details and instructions on each of the coverage exemption types listed above. 
     
    If there are more than five (5) members in your tax household, please complete multiple IND-HEALTH Forms.    
    Name:                     
                                                        Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
                              Checkü if under 
    Social Security Number: 
                              18 years of age 
 1)                           as of 01/01/2023
                     
    Exemption Number:                              Number of months for which an exemption did not apply:
    Name:                     
                                                        Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
     
    Social Security Number:   Checkü if under 
 2)                           18 years of age 
                              as of 01/01/2023
                     
    Exemption Number:                              Number of months for which an exemption did not apply:
    Name:                     
                                                        Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
     
    Social Security Number:   Checkü if under 
 3)                           18 years of age 
                              as of 01/01/2023
                     
    Exemption Number:                              Number of months for which an exemption did not apply:
                              
     Name:                                              Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
     
    Social Security Number:   Checkü if under 
 4)                           18 years of age 
                              as of 01/01/2023
                     
    Exemption Number:                              Number of months for which an exemption did not apply:
                              
     Name:
                                                        Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
                       
    Social Security Number:   Checkü if under 
 5)                           18 years of age 
                              as of 01/01/2023
                     
    Exemption Number:                              Number of months for which an exemption did not apply:
       6a) Total periods that adults did not have coverage:        6b) Total periods that children did not have coverage: