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CAUTION: NOT FOR FILING

Form 1095-A is provided here for informational purposes only.

Health Insurance Marketplaces use Form 1095-A to report information on 
enrollments in a qualified health plan in the individual market through the 
Marketplace. As the form is to be completed by the Marketplaces, 
individuals cannot complete and use Form 1095-A available on IRS.gov. 
Individuals receiving a completed Form 1095-A from the Health Insurance 
Marketplace will use the information received on the form and the guidance 
in the instructions to assist them in filing an accurate tax return.



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Form  1095-A                 Health Insurance Marketplace Statement                                              VOID                 OMB No. 1545-2232

Department of the Treasury        Do not attach to your tax return. Keep for your records.                       CORRECTED
Internal Revenue Service   Go to www.irs.gov/Form1095A for instructions and the latest information.                                   2023

Part I      Recipient Information
1  Marketplace identifier                   2  Marketplace-assigned policy number    3  Policy issuer’s name

4  Recipient’s name                                                                  5  Recipient’s SSN                 6  Recipient’s date of birth

7  Recipient’s spouse’s name                                                         8  Recipient’s spouse’s SSN        9  Recipient’s spouse’s date of birth

10  Policy start date                       11  Policy termination date           12  Street address (including apartment no.)

13  City or town                            14  State or province                 15  Country and ZIP or foreign postal code

Part II     Covered Individuals

                 A. Covered individual name   B. Covered individual SSN           C. Covered individual     D. Coverage start date E. Coverage termination date
                                                                                     date of birth

16

17

18

19

20
Part III    Coverage Information
            Month                A. Monthly enrollment premiums         B. Monthly second lowest cost silver     C. Monthly advance payment of 
                                                                          plan (SLCSP) premium                           premium tax credit

21   January

22   February

23   March

24   April

25   May

26   June

27   July

28   August

29   September

30   October

31   November

32   December

33   Annual Totals
For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.                          Cat. No. 60703Q               Form 1095-A (2023) 



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Form 1095-A (2023)                                                                                                                            Page 2 
                                                                            If advance credit payments are made, the only individuals listed on 
Instructions for Recipient                                                  Form 1095-A will be those whom you certified to the Marketplace would 
You received this Form 1095-A because you or a family member                be in your tax family for the year of coverage (yourself, spouse, and 
enrolled in health insurance coverage through the Health Insurance          dependents). If you certified to the Marketplace at enrollment that one or 
Marketplace. This Form 1095-A provides information you need to              more of the individuals who enrolled in the plan aren’t individuals who 
complete Form 8962, Premium Tax Credit (PTC). You must complete             would be in your tax family for the year of coverage, those individuals 
Form 8962 and file it with your tax return (Form 1040, Form                 won’t be listed on your Form 1095-A. For example, if you indicated to 
1040-SR, or Form 1040-NR) if any amount other than zero is shown            the Marketplace at enrollment that an individual enrolling in the policy is 
in Part III, column C, of this Form 1095-A (meaning that you                your adult child who will not be your dependent for the year of coverage, 
received premium assistance through advance payments of the                 that child will receive a separate Form 1095-A and won’t be listed in 
premium tax credit (also called advance credit payments)) or if you         Part II on your Form 1095-A.
want to take the premium tax credit. The filing requirement applies         If advance credit payments are made and you certify that one or more 
whether or not you’re otherwise required to file a tax return. If you are   enrolled individuals aren’t individuals who would be in your tax family for 
filing Form 8962, you cannot file Form 1040-NR-EZ, Form                     the year of coverage, your Form 1095-A will include coverage 
1040-SS, or Form 1040-PR. The Marketplace has also reported the             information in Part III that is applicable solely to the individuals listed on 
information on this form to the IRS. If you or your family members          your Form 1095-A, and separately issued Forms 1095-A will include 
enrolled at the Marketplace in more than one qualified health plan          coverage information, including dollar amounts, applicable to those 
policy, you will receive a Form 1095-A for each policy. Check the           individuals not in your tax family.
information on this form carefully. Please contact your Marketplace if 
you have questions concerning its accuracy. If you or your family           If advance credit payments weren’t made and you didn’t identify at 
members were enrolled in a Marketplace catastrophic health plan or          enrollment the individuals who would be in your tax family for the year of 
separate dental policy, you aren’t entitled to take a premium tax credit    coverage, Form 1095-A will list all enrolled individuals in Part II on your 
for this coverage when you file your return, even if you received a Form    Form 1095-A.
1095-A for this coverage. For additional information related to Form        If there are more than five individuals covered by a policy, you will 
1095-A, go to www.irs.gov/Affordable-Care-Act/Individuals-and-              receive one or more additional Forms 1095-A that continue Part II.
Families/Health-Insurance-Marketplace-Statements.                           Part III. Coverage Information, lines 21–33. Part III reports information 
Additional information. For additional information about the tax            about your insurance coverage that you will need to complete Form 
provisions of the Affordable Care Act (ACA), including the premium tax      8962 to reconcile advance credit payments or to take the premium tax 
credit, see www.irs.gov/Affordable-Care-Act/Individuals-and-Families or     credit when you file your return.
call the IRS Healthcare Hotline for ACA questions (800-919-0452).           Column A. This column is the monthly premiums for the plan in which 
VOID box. If the “VOID” box is checked at the top of the form, you          you or family members were enrolled, including premiums that you paid 
previously received a Form 1095-A for the policy described in Part I.       and premiums that were paid through advance payments of the 
That Form 1095-A was sent in error. You shouldn’t have received a           premium tax credit. If you or a family member enrolled in a separate 
Form 1095-A for this policy. Don’t use the information on this or the       dental plan with pediatric benefits, this column includes the portion of 
previously received Form 1095-A to figure your premium tax credit on        the dental plan premiums for the pediatric benefits. If your plan covered 
Form 8962.                                                                  benefits that aren’t essential health benefits, such as adult dental or 
CORRECTED box. If the “CORRECTED” box is checked at the top of              vision benefits, the amount in this column will be reduced by the 
the form, use the information on this Form 1095-A to figure the premium     premiums for the nonessential benefits. If the policy was terminated by 
tax credit and reconcile any advance credit payments on Form 8962.          your insurance company due to nonpayment of premiums for 1 or more 
Don’t use the information on the original Form 1095-A you received for      months, then a -0- will appear in this column for these months 
this policy.                                                                regardless of whether advance credit payments were made for these 
                                                                            months. See the instructions for Form 8962, Part II, on how to complete 
Part I. Recipient Information, lines 1–15. Part I reports information       Form 8962 if -0- is reported for 1 or more months.
about you, the insurance company that issued your policy, and the 
Marketplace where you enrolled in the coverage.                             Column B. This column is the monthly premium for the second lowest 
                                                                            cost silver plan (SLCSP) that the Marketplace has determined applies to 
Line 1. This line identifies the state where you enrolled in coverage       members of your family enrolled in the coverage. The applicable SLCSP 
through the Marketplace.                                                    premium is used to compute your monthly advance credit payments 
Line 2. This line is the policy number assigned by the Marketplace to       and the premium tax credit you take on your return. See the instructions 
identify the policy in which you enrolled. If you are completing Part IV of for Form 8962, Part II, on how to use the information in this column or 
Form 8962, enter this number on line 30, 31, 32, or 33, box a.              how to complete Form 8962 if there is no information entered, the 
Line 3. This is the name of the insurance company that issued your          information is incorrect, or the information is reported as -0-. If the 
policy.                                                                     policy was terminated by your insurance company due to nonpayment 
                                                                            of premiums for 1 or more months, then a -0- will appear in this column 
Line 4. You are the recipient because you are the person the                for the months, regardless of whether advance credit payments were 
Marketplace identified at enrollment who is expected to file a tax return   made for these months.
and who, if qualified, would take the premium tax credit for the year of 
coverage.                                                                   Column C. This column is the monthly amount of advance credit 
                                                                            payments that were made to your insurance company on your behalf to 
Line 5. This is your social security number (SSN). For your protection,     pay for all or part of the premiums for your coverage. If this is the only 
this form may show only the last four digits. However, the Marketplace      column in Part III that is filled in with an amount other than zero for a 
has reported your complete SSN to the IRS.                                  month, it means your policy was terminated by your insurance company 
Line 6. A date of birth will be entered if there is no SSN on line 5.       due to nonpayment of premiums, and you aren’t entitled to take the 
Lines 7, 8, and 9. Information about your spouse will be entered only if    premium tax credit for that month when you file your tax return. You 
advance credit payments were made for your coverage. The date of            must still reconcile the entire advance payment that was paid on your 
birth will be entered on line 9 only if line 8 is blank.                    behalf for that month using Form 8962. No information will be entered in 
                                                                            this column if no advance credit payments were made. 
Lines 10 and 11. These are the starting and ending dates of the policy.
                                                                            Lines 21–33. The Marketplace will report the amounts in columns A, B, 
Lines 12 through 15. Your address is entered on these lines.                and C on lines 21–32 for each month and enter the totals on line 33. Use 
Part II. Covered Individuals, lines 16–20. Part II reports information      this information to complete Form 8962, line 11 or lines 12–23.
about each individual who is covered under your policy. This information 
includes the name, SSN, date of birth, and the starting and ending dates 
of coverage for each covered individual. For each line, a date of birth is 
reported in column C only if an SSN isn’t entered in column B. 






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