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4 State of Rhode Island Division of Taxation 4
5 Form IND-HEALTH 5
6 Individual Health Insurance Mandate Form 23106299990101 6
7 7
8 Name Social security number 8
9 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 999999999 9
10 10
11 Coverage Exemption Reasons and Codes 11
12 12
Aggregate Self Only Coverage G1
13 Income Below Filing Threshold NC Considered Unaffordable 13
14 Member of Tax Household Born 14
Coverage Considered Unaffordable A or Adopted During the Year H1
15 15
16 Short Coverage Gap B Member of Tax Household Died During the Year H2 16
17 Citizens Living Abroad & Certain Noncitizens C Nonresident of Rhode Island N 17
18 18
19 Members of Healthcare Sharing Ministry D Had Minimum Essential Health Coverage X 19
20 Members of Indian Tribes E HealthSource RI Exemption RI 20
21 Incarceration F Medicaid M 21
22 Enter the name and social security number for each member of your tax household. For each household member, use the chart above to enter 22
23 an exemption code for each corresponding month in which the household member had minimum essential health coverage or an exemption. If 23
24 an individual qualified for an exemption through HealthSource RI, enter the exemption number(s) in the space provided. 24
25 Refer to the Individual Mandate Instructions for details and instructions on each of the coverage exemption types listed above. 25
26 If there are more than five (5) members in your tax household, please complete multiple IND-HEALTH Forms. 26
27 Name: 27
28 28
XXXXXXXXXXXXXXXXXXXXXXXX Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
29 29
Social Security Number:
30 Checkü if under 30
18 years of age
1)31 999999999 as of 01/01/2023 XX XX XX XX XX XX XX XX XX XX XX XX 31
32 32
33 Exemption Number: 9999999999999 Number of months for which an exemption did not apply: XXXXXXX 33
34 Name: 34
35 XXXXXXXXXXXXXXXXXXXXXXXXX Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 35
36 36
37 Social Security Number: Checkü if under 37
2)38 999999999 18 years of age XX XX XX XX XX XX XX XX XX XX XX XX 38
as of 01/01/2023
39 39
40 Exemption Number: 9999999999999 Number of months for which an exemption did not apply: XXXXXXX 40
41 Name: 41
42 XXXXXXXXXXXXXXXXXXXXXXXXDRAFTJan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 42
43 43
44 Social Security Number: Checkü if under 44
as of 01/01/2023
3)45 999999999 18 years of age XX XX XX XX XX XX XX XX XX XX XX XX 45
46 46
47 Exemption Number: 9999999999999 Number of months for which an exemption did not apply: XXXXXXX 47
48 48
49 Name: XXXXXXXXXXXXXXXXXXXXXXXX Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 49
50 50
51 Social Security Number: Checkü if under 51
4) 18 years of age
52 52
999999999 as of 01/01/2023 09/01/2023XX XX XX XX XX XX XX XX XX XX XX XX
53 53
54 Exemption Number: 9999999999999 Number of months for which an exemption did not apply: XXXXXXX 54
55 55
56 Name: XXXXXXXXXXXXXXXXXXXXXXXX 56
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
57 57
58 Social Security Number: Checkü if under 58
5) 18 years of age
59 999999999 as of 01/01/2023 XX XX XX XX XX XX XX XX XX XX XX XX 59
60 60
61 Exemption Number: 9999999999999 Number of months for which an exemption did not apply: XXXXXXX 61
62 6a) Total periods that adults did not have coverage: 6b) Total periods that children did not have coverage: 62
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