Responsibility Unable Details

What is an application exemption? An application exemption is a document that exempts a specified type of building from the requirements for complying with the accessibility standards. This blog post will discuss what this means, and some common types of exemptions. What are some types of application exemptions? -One example would be a structural alteration to an existing public or commercial building. There may also be demolition permits for buildings which have been structurally altered so as to make them unsuitable for occupation by human beings. In these cases, there may not need to be compliance with certain features such as accessible entrances on every street frontage, ramps at all entry points, wide doorways etc.

You can find information about the type of form you need to fill out in the table. It can tell you the amount of time you'll need to fill out application exemption, what fields you will have to fill in, etc.

QuestionAnswer
Form NameApplication Exemption
Form Length13 pages
Fillable?No
Fillable fields0
Avg. time to fill out3 min 15 sec
Other namesapplication exemption online, responsibility unable, application exemption, exemption shared

Form Preview Example

FFM-AFFORDABILITY

Form Approved

OMB No. 0938-1190

Application for Exemption from the Shared Responsibility

Sd|phqw#iru#Iqglylgxdov#zkr#duh#Xqdeoh#wr#Dfrug#Fryhudjh#dqg#

are in a State with a Federally Facilitated Marketplace

Use this application to apply for

an exemption from the shared responsibility payment

Starting in 2014, every person needs to have health insurance or make a payment on his or her federal income tax return. This is called the “shared responsibility payment.”

Some people are exempt from making this payment. This application includes one category of exemption. There are other applications for

other categories of exemptions, and you’ll also see some exemption fdwhjrulhv#zkhq#|rx#ioh#|rxu#ihghudo#lqfrph#wd{#uhwxuq1

\rx#grq’w#qhhg#wr#dvn#iru#dq#h{hpswlrq#li#|rx’uh#qrw#jrlqj#wr#ioh#d ihghudo#lqfrph#wd{#uhwxuq#ehfdxvh#|rxu#lqfrph#lv#ehorz#wkh#iolqj threshold. If you aren’t sure, you may want to ask for an exemption.

THINGS TO KNOW

Who can use this

Xvh#wklv#dssolfdwlrq#li#|rx’uh#xqdeoh#wr#dfrug#fryhudjh1#Ii

 

|rx#jhw#wklv#h{hpswlrq/#|rx#pd|#eh#deoh#wr#ex|#fdwdvwursklf

application?

 

 

fryhudjh1

 

 

 

• Use this application to ask for an exemption for months in the future.

 

 

If you want this exemption for a whole calendar year, you need to

 

 

request it before the year starts. You can also claim an exemption on

 

 

|rxu#ihghudo#lqfrph#wd{#uhwxuq#li#|rx’uh#xqdeoh#wr#dfrug#fryhudjh1

 

• You can use one application to ask for this exemption for more than

 

 

one person in your tax household.

What you need

• Social Security numbers (SSNs), if you have them.

to apply

• Employer and income information for everyone in your family (for

 

 

example, from pay stubs, W-2 forms, or wage and tax statements.)

 

• Information about any job-related health insurance available to

 

 

your family.

 

• Proof of your yearly income for 2014. See page 9 for examples of

 

 

documents you can send.

Why do we ask for

We ask for Social Security numbers and other information to make

this information?

vxuh#|rxu#h{hpswlrq#lv#frxqwhg#zkhq#|rx#ioh#|rxu#ihghudo#lqfrph#wd{#

return. Zh’oo#nhhs#doo#wkh#lqirupdwlrq#|rx#jlyh#sulydwh#dqg#vhfxuh/#

 

dv#uhtxluhg#e|#odz1 To view the Privacy Act Statement, go to

 

KhdowkFduh1jry or see instructions.

 

 

What happens

Send your complete, signed application to the address on page 8.

next?

We’ll follow-up with you within 1–2 weeks and let you know if we need

additional information. If you get this exemption, we’ll give you an

 

 

H{hpswlrq#Fhuwlifdwh#Qxpehu#wkdw#|rx’oo#sxw#rq#|rxu#ihghudo#lqfrph#wd{#

 

return. If you don’t hear from us, visit KhdowkFduh1jry, or call the Health

 

Insurance Marketplace Help Center at 1-800-318-2596. TTY users should

 

call 1-855-889-4325.

Get help with this

Online: KhdowkFduh1jry.

application

Phone: Call the Health Insurance Marketplace Call Center at

 

 

1-800-318-2596.

In person: There may be counselors in your area who can help. Visit KhdowkFduh1jry or call 1-800-318-2596 for more information.

En Español: Llame a nuestro centro de ayuda gratis al 1-800-318-2596.

NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or call us at 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 and tell the customer service representative the language you need. We’ll get you help at no cost to you. TTY users should call 1-855-889-4325.

FFM-AFFORDABILITY

Xvh#eoxh#ru#eodfn#lqn#wr#frpsohwh#wklv#dssolfdwlrq1

Page 1 of 9

STEP 1 Whoo#xv#derxw#|rxuvhoi1

(We need one adult in the tax household to be the contact person for your application.)

Are you in Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Idaho, Illinois, Indiana, Iowa, Kansas, Louisiana, Maine, Michigan, Mississippi, Missouri, Montana, Nebraska, New Hampshire, New Jersey, New Mexico, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Virginia, West Virginia, Wisconsin, or Wyoming?

YES. Fill out this application.

NO. Visit KhdowkFduh1jry/#ru#fdoo#40;33064;058<9#wr#iqg#rxw#krz#wr#dsso|#iru#wklv#h{hpswlrq1#

1. First name

Middle name

Last name

Suffix

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

3. Apartment or suite number

4. City

5. State

6. ZIP code

7. County

8. Mailing address (if different from home address)

9. Apartment or suite number

10. City

 

 

 

 

 

 

 

 

 

 

 

11. State

12. ZIP code

 

 

 

 

 

 

 

13. County

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

14. Phone number

 

 

 

 

 

 

 

 

 

 

 

 

 

15. Other phone number

 

 

 

 

 

 

 

 

(

 

 

 

)

 

 

 

 

 

 

 

 

 

 

 

 

(

 

 

 

 

 

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

16. Do you want to get information about this application by email? Yes No

Email address:

17. What is your preferred spoken or written language (if not English)?

STEP 2 Whoo#xv#derxw#|rxu#idplo|1

Who do you need to include on this application?

Whoo#xv#derxw#doo#wkh#idplo|#phpehuv#zkr#olyh#zlwk#|rx1#Ii#|rx#ioh#wd{hv/#zh#qhhg#wr#nqrz#derxw#hyhu|rqh#rq#|rxu#ihghudo#lqfrph# wd{#uhwxuq1#+Ii#|rx#jhw#wklv#h{hpswlrq/#|rx’oo#qhhg#wr#ioh#wd{hv#wr#xvh#lw1,#Ii#|rx#jhw#wklv#h{hpswlrq/#zh’oo#jlyh#|rx#dq#H{hpswlrq#

Fhuwlifdwh#Qxpehu#zlwk#|rxu#dssurydo#ohwwhu1#Nhhs#wklv#iru#|rxu#uhfrugv1#\rx’oo#qhhg#wr#sxw#wklv#qxpehu#rq#|rxu#ihghudo#lqfrph# wd{#uhwxuq#dw#wkh#wlph#|rx#ioh#wd{hv1#

DO Include:

Your spouse

Your children under 21 who live with you

Your unmarried partner who needs health coverage

Anyone you put on your tax return, even if they don’t live with you

Anyone else under 21 you take care of and who lives with you

You DON’T have to include:

Your unmarried partner who doesn’t need health coverage

Your unmarried partner’s children

\rxu#sduhqwv#zkr#olyh#zlwk#|rx/#exw#ioh#wkhlu#rzq#wd{ return (if you’re over 21)

Rwkhu#dgxow#uhodwlyhv#zkr#ioh#wkhlu#rzq#wd{#uhwxuq

This information helps us make sure everyone gets the exemption that they qualify for.

Frpsohwh#Vwhs#5#iru#hdfk#shuvrq#lq#|rxu#idplo|1#

Start with yourself, then add other adults and children. If you have more than 2 people in your family, you’ll need to make copies of pages 5–7 and attach them. You don’t need to provide immigration status or a Social Security number (SSN) for family members who don’t need an exemption. We’ll keep all the information you provide private and secure, as required by law. We’ll use personal information only to check if you’re eligible for an exemption.

NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or call us at 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 and tell the customer service representative the language you need. We’ll get you help at no cost to you. TTY users should call 1-855-889-4325.

FFM-AFFORDABILITY

Page 2 of 9

STEP 2: PERSON 1

Complete Step 2 for yourself, your spouse/partner and children who live with you and/or anyone on your same federal income tax return if you

ioh#rqh1#Vhh#sdjh#4#iru#pruh#lqirupdwlrq#derxw#zkr#wr#lqfoxgh1#Ii#|rx#grq’w#ioh#d#wd{#uhwxuq/#uhphpehu#wr#vwloo#dgg#idplo|#phpehuv#zkr#olyh# with you.

1.

First name

Middle name

 

 

 

 

Last name

 

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

Relationship to you

 

3. Date of birth (mm/dd/yyyy)

4. Sex

 

SELF

 

 

 

 

 

/

 

 

 

/

 

 

 

 

 

Male

Female

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

-

 

 

 

 

 

 

 

 

 

5.

Social Security number (SSN)

 

 

 

 

-

 

 

 

 

 

 

 

 

 

 

 

Ii#|rx’uh#uhtxhvwlqj#dq#h{hpswlrq#iru#|rxuvhoi#dqg#|rx#kdyh#dq#VVQ/#|rx#pxvw#surylgh#lw1#\rx#duhq’w#uhtxluhg#wr#kdyh#dq#VVQ#wr#

jhw#wklv#h{hpswlrq1#Ii#|rx’uh#qrw#uhtxhvwlqj#dq#h{hpswlrq#iru#|rxuvhoi/#surylglqj#|rxu#VVQ#fdq#eh#khosixo#ehfdxvh#lw#fdq#vshhg#xs# wkh#dssolfdwlrq#surfhvv1 We use SSNs to check income and other information to see who is eligible for an exemption, and to help make sure that if you get an exemption, it’s applied correctly on your taxes. If you need help getting an SSN, visit vrfldovhfxulw|1jry/#or call

1-800-772-1213. TTY users should call 1-800-325-0778.

91 Whoo#xv#derxw#wkh#ihghudo#lqfrph#wd{#uhwxuq#wkdw#|rx#sodq#wr#iloh1

a.Zloo#|rx#ioh#mrlqwo|#zlwk#d#vsrxvhB# Yes

Ii#|hv/ name of spouse:

No

b. Will you claim any dependents on his or her tax return?

Yes

No

 

 

Ii#|hv/ list name(s) of dependents:

 

 

 

 

 

 

 

 

c. Will you be claimed as a dependent on someone’s tax return?

Yes

No

Ii#|hv/#sohdvh#olvw#wkh#qdph#ri#wkh#wd{#iohu=

 

 

 

 

 

Krz#duh#|rx#uhodwhg#wr#wkh#wd{#iohuB

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7. Do you need this exemption?

\HV1#

QR1# Ii#qr/ leave the rest of the page blank.

8. Ii#Klvsdqlf2Odwlqr/#hwkqlflw|#+OPTIONAL fkhfn#doo#wkdw#dsso|1,

Mexican

Mexican American

Chicano/a

Puerto Rican

Cuban

Other

9. Udfh#+OPTIONAL fkhfn#doo#wkdw#dsso|1,

White

Black or African American

American Indian or Alaska Native Asian Indian Chinese

Filipino

Japanese

Korean

Vietnamese

Other Asian

Native Hawaiian

Guamanian or Chamorro Samoan

Rwkhu#Sdflif#Ivodqghu#

Other

NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or call us at 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 and tell the customer service representative the language you need. We’ll get you help at no cost to you. TTY users should call 1-855-889-4325.

FFM-AFFORDABILITY

Page 3 of 9

STEP 2: PERSON 1 +Frqwlqxh#zlwk#|rxuvhoi,

Fxuuhqw#mre#)#lqfrph#lqirupdwlrq#

Employed: If you’re currently employed, tell us about your income. Start with question 10.

Not employed: Skip to question 20.

Self-employed: Skip to question 19.

FXUUHQW#MRE#4=#

10.

Employer name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a. Employer address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b. City

 

 

c. State

 

d. ZIP code

11.

Employer phone number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

 

 

 

 

 

 

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12.

Wages/tips (before taxes)

Hourly

 

 

Weekly

 

Every 2 weeks

13.

Average hours worked each WEEK

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

Twice a month

 

 

Monthly

 

Yearly

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FXUUHQW#MRE#5=#(If you have more jobs and need more space, attach another sheet of paper.)

14.Employer name

a. Employer address

b. City

 

c. State

 

d. ZIP code

15.

Employer phone number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

 

 

 

 

 

 

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

16. Wages/tips (before taxes)

Hourly

 

 

Weekly

 

Every 2 weeks

17.

Average hours worked each WEEK

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

Twice a month

 

 

Monthly

 

Yearly

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

18. Iq#wkh#sdvw#|hdu/#glg#|rx=# Change jobs

Stop working

Start working fewer hours

None of these

19. Ii#vhoi0hpsor|hg/#dqvzhu#wkh#iroorzlqj#txhvwlrqv=

a. Type of work:

 

 

 

 

 

 

 

 

b. How much net income (profits once business expenses are paid) will you get from

$

 

 

 

 

 

 

 

 

 

 

 

 

this self-employment this month? (SEE INSTRUCTIONS.)

 

 

 

 

 

 

 

 

 

 

 

 

 

20. RWKHU#IQFRPH#WKIV#PRQWK=#Check all that apply, and give the amount and how often you get it. Check here if none.

NOTE: You don’t need to tell us about child support, veteran’s payment, Supplemental Security Income (SSI), or old age, survivor’s, or glvdelolw|#ehqhiwv#iurp#Vrfldo#Vhfxulw|#wkdw#duhq’w#wd{deoh1#

Unemployment

Pension

Social Security

Retirement accounts

$

$

$

$

How often?

How often?

How often?

How often?

Alimony received

Net farming/fishing

Net rental/royalty

Other income

Type:

$

$

$

$

How often?

How often?

How often?

How often?

21. GHGXFWIRQV: Check all that apply, and give the amount and how often you get it.

NOTE: You shouldn’t include a cost that you already considered in your answer to net self-employment (question 19).

Alimony paid

Student loan interest

$

$

How often?

How often?

Other deductions

$

Type:

 

 

How often?

22.\HDUO\#IQFRPH=#Frpsohwh#rqo|#li#|rxu#lqfrph#fkdqjhv#iurp#prqwk#wr#prqwk1 Ii#|rx#grq’w#h{shfw#fkdqjhv#wr#|rxu#prqwko|#lqfrph/#vnls#wr#wkh#qh{w#shuvrq1#

Your total income this year

Your total income next |hdu#+li#|rx#wklqn#lw#zloo#eh#glfhuhqw,#

$

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

23.If your employer withholds some of your wages and use them to pay for health insurance, list the amount that is withheld each year:

$

NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or call us at 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 and tell the customer service representative the language you need. We’ll get you help at no cost to you. TTY users should call 1-855-889-4325.

FFM-AFFORDABILITY

Page 4 of 9

STEP 2: PERSON 1 +Frqwlqxh#zlwk#|rxuvhoi,

24.Duh#|rx#riihuhg#khdowk#fryhudjh#iurp#d#mreB

Check yes even if the coverage is from someone else’s job, such as a parent or spouse.

\HV1#If yes, you’ll need to complete and include Appendix A, and then skip to Step 3. Is this a state employee benefit plan?

QR1#Ii#qr/#dqvzhu#doo#wkh#txhvwlrqv#ehorz#iru#rwkhu#khdowk#fryhudjh1

Yes

No

RWKHU#KHDOWK#FRYHUDJH=#

25.Duh#|rx#hquroohg#lq#khdowk#fryhudjh#qrz#iurp#wkh#iroorzlqjB

\HV1#If yes, check the type of coverage.

QR1

Medicaid

CHIP Medicare

TRICARE (Don’t check if you have direct care or Line of Duty) VA health care programs

Peace Corps

Employer insurance

 

 

Is this COBRA coverage?

Yes

No

Is this a retiree health plan?

Yes

No

Other

Iv#wklv#d#olplwhg0ehqhiw#sodq#+olnh#d#vfkrro#dfflghqw#srolf|,B

Yes

No

26.

Are you pregnant?

Yes.

No.

a. If yes, how many babies are expected during this pregnancy?

 

 

 

 

 

 

27.

Do you live with at least one child under 19, and are you the main person taking care of this child?

Yes

No

 

 

 

 

 

 

 

 

28.

Are you a full-time student?

Yes

No

 

 

 

 

 

 

 

 

 

 

29.

Were you in foster care at age 18 or older?

Yes

No

 

 

30. Within the past 6 months, have you used tobacco regularly (4 or more times per week on average excluding religious or ceremonial uses)?

Yes

No

31. Are you a U.S. citizen or U.S. national?

Yes

No

32.Ii#|rx#duhq’w#d#X1V1#flwl}hq#ru#X1V1#qdwlrqdo/ do you have eligible immigration status? (SEE INSTRUCTIONS.)

Yes. Fill in your document type and ID number below.

 

a. Immigration document type:

 

b. Document ID number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c. Have you lived in the U.S. since 1996?

 

d. Are you, or your spouse or parent, a veteran or an active-duty

 

Yes

No

 

member of the U.S. military?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WKDQNV$#Wklv#lv#doo#zh#qhhg#wr#nqrz#derxw#|rx1

NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or call us at 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 and tell the customer service representative the language you need. We’ll get you help at no cost to you. TTY users should call 1-855-889-4325.

FFM-AFFORDABILITY

Page 5 of 9

STEP 2: PERSON 2

Ii#|rx#kdyh#pruh#wkdq#wzr#shrsoh#wr#lqfoxgh/#pdnh#d#frs|#ri

Vwhs#5=#Shuvrq#5#+sdjhv#8/#9#dqg#:,#dqg#frpsohwh1#

Complete Step 2 for yourself, your spouse/partner and children who live with you and/or anyone on your same federal income tax return if you

ioh#rqh1#Vhh#sdjh#4#iru#pruh#lqirupdwlrq#derxw#zkr#wr#lqfoxgh1#Ii#|rx#grq’w#ioh#d#wd{#uhwxuq/#uhphpehu#wr#vwloo#dgg#idplo|#phpehuv#zkr#olyh# with you.

1. First name

Middle name

Last name

Suffix

2. Relationship to you

3. Date of birth (mm/dd/yyyy)

/ /

4. Sex

Male

Female

5. Social Security number (SSN)

-

-

Ii#|rx’uh#uhtxhvwlqj#dq#h{hpswlrq#iru#SHUVRQ#5,#dqg#SHUVRQ#5#kdv#dq#VVQ/#|rx#pxvw#surylgh#lw1#SHUVRQ#5#lvq’w#uhtxluhg#wr#kdyh# dq#VVQ#wr#jhw#wklv#h{hpswlrq1#Ii#|rx’uh#qrw#uhtxhvwlqj#dq#h{hpswlrq#iru#SHUVRQ#5/#surylglqj#SHUVRQ#5’v#VVQ#fdq#eh#khosixo#

ehfdxvh#lw#fdq#vshhg#xs#wkh#dssolfdwlrq#surfhvv1#We use SSNs to check income and other information to see who is eligible for an

exemption, and to help make sure that if PERSON 2 gets an exemption, it’s applied correctly on their taxes. If PERSON 2 needs help getting an SSN, visit vrfldovhfxulw|1jry, or call 1-800-772-1213. TTY users should call 1-800-325-0778.

91 Whoo#xv#derxw#wkh#ihghudo#lqfrph#wd{#uhwxuq#wkdw#SHUVRQ#5#sodqv#wr#iloh1

a.Zloo#SHUVRQ#5#ioh#mrlqwo|#zlwk#d#vsrxvhB# Yes No

Ii#|hv/ name of spouse:

 

b. Will PERSON 2 claim any dependents on his or her tax return?

Yes

No

 

 

 

 

 

 

 

Ii#|hv/ list name(s) of dependents:

 

 

 

 

 

 

 

 

 

 

 

 

 

c. Will PERSON 2 be claimed as a dependent on someone’s tax return?

Yes

No

 

 

 

 

 

Ii#|hv/#sohdvh#olvw#wkh#qdph#ri#wkh#wd{#iohu=

 

 

 

 

 

 

 

 

 

 

 

Krz#duh#|rx#uhodwhg#wr#wkh#wd{#iohuB

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7.

Does PERSON 2 need this exemption?

 

 

 

 

 

 

 

 

 

 

\HV1#

QR1#

Ii#qr/ leave the rest of the page blank.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8.

Ii#Klvsdqlf2Odwlqr/#hwkqlflw|#+OPTIONAL fkhfn#doo#wkdw#dsso|1,

 

 

 

 

 

 

 

 

 

Mexican

Mexican American

Chicano/a

Puerto Rican

Cuban

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9.

Udfh#+OPTIONAL

fkhfn#doo#wkdw#dsso|1,

 

 

 

 

 

 

 

 

 

 

White

 

American Indian or

Filipino

 

 

Vietnamese

Guamanian or Chamorro

 

 

Black or African

Alaska Native

Japanese

 

 

Other Asian

Samoan

 

 

American

 

Asian Indian

Korean

 

 

Native Hawaiian

Rwkhu#Sdflif#Ivodqghu#

 

 

 

 

Chinese

 

 

 

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or call us at 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 and tell the customer service representative the language you need. We’ll get you help at no cost to you. TTY users should call 1-855-889-4325.

FFM-AFFORDABILITY

Page 6 of 9

STEP 2: PERSON 2

Fxuuhqw#mre#)#lqfrph#lqirupdwlrq#

Employed: If PERSON 2 is currently employed, tell us about his or her income. Start with question 10..

Not employed: Skip to question 20.

Self-employed: Skip to question 19.

FXUUHQW#MRE#4=#

10.

Employer name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a. Employer address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b. City

 

 

c. State

 

d. ZIP code

11.

Employer phone number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

 

 

 

 

 

 

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12.

Wages/tips (before taxes)

Hourly

 

 

Weekly

 

Every 2 weeks

13.

Average hours worked each WEEK

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

Twice a month

 

 

Monthly

 

Yearly

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FXUUHQW#MRE#5=#(If PERSON 2 has more jobs, attach another sheet of paper.)

14.Employer name

a. Employer address

b. City

 

 

 

c. State

 

d. ZIP code

 

15. Employer phone number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

 

 

 

 

 

 

 

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

16.

Wages/tips (before taxes)

Hourly

 

Weekly

 

 

Every 2 weeks

 

17. Average hours worked each WEEK

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

Twice a month

 

Monthly

 

 

Yearly

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

18.

Iq#wkh#sdvw#|hdu/#glg#SHUVRQ#5=#

Change jobs

 

Stop working

 

Start working fewer hours

None of these

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

19.

Ii#SHUVRQ#5#lv#vhoi0hpsor|hg/#dqvzhu#wkh#iroorzlqj#txhvwlrqv=

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a. Type of work:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b. How much net income (profits once business expenses are paid) will PERSON 2

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

get from this self-employment this month? (SEE

INSTRUCTIONS.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

20. RWKHU#IQFRPH#WKIV#PRQWK=#Check all that apply, and give the amount and how often PERSON 2 gets it. Check here if none.

NOTE: You don’t need to tell us about PERSON 2’s child support, veteran’s payment, Supplemental Security Income (SSI), or old age, survivor’s, ru#glvdelolw|#ehqhiwv#iurp#Vrfldo#Vhfxulw|#wkdw#duhq’w#wd{deoh1#

Unemployment

Pension

Social Security

Retirement accounts

$

$

$

$

How often?

How often?

How often?

How often?

Alimony received

Net farming/fishing

Net rental/royalty

Other income

Type:

$

$

$

$

How often?

How often?

How often?

How often?

21. GHGXFWIRQV: Check all that apply, and give the amount and how often PERSON 2 gets it.

NOTE: You shouldn’t include a cost that you already considered in your answer to net self-employment (question 19).

Alimony paid

Student loan interest

$

$

How often?

How often?

Other deductions

$

Type:

 

 

How often?

22.\HDUO\#IQFRPH=#Frpsohwh#rqo|#li#SHUVRQ#5’v#lqfrph#fkdqjhv#iurp#prqwk#wr#prqwk1 Ii#|rx#grq’w#h{shfw#fkdqjhv#wr#SHUVRQ#5’v#prqwko|#lqfrph/#vnls#wr#wkh#qh{w#shuvrq1#

PERSON 2’s total income this year PERSON 2’s total income next |hdu#+li#|rx#wklqn#lw#zloo#eh#glfhuhqw,#

$

$

23.If PERSON’s employer withholds some of their wages and use them to pay for health insurance, list the amount that is withheld each year:

$

NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or call us at 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 and tell the customer service representative the language you need. We’ll get you help at no cost to you. TTY users should call 1-855-889-4325.

FFM-AFFORDABILITY

Page 7 of 9

STEP 2: PERSON 2

24.Iv#SHUVRQ#5#riihuhg#khdowk#fryhudjh#iurp#d#mreB

Check yes even if the coverage is from someone else’s job, such as a parent or spouse.

\HV1#If yes, you’ll need to complete and include Appendix A, and then skip to Step 3. Is this a state employee benefit plan?

QR1#Ii#qr/#dqvzhu#doo#wkh#txhvwlrqv#ehorz#iru#rwkhu#khdowk#fryhudjh1

Yes

No

RWKHU#KHDOWK#FRYHUDJH=#

25.Iv#SHUVRQ#5#hquroohg#lq#khdowk#fryhudjh#qrz#iurp#wkh#iroorzlqjB

\HV1#If yes, check the type of coverage.

QR1

Medicaid

CHIP Medicare

TRICARE (Don’t check if you have direct care or Line of Duty) VA health care programs

Peace Corps

Employer insurance

 

 

Is this COBRA coverage?

Yes

No

Is this a retiree health plan?

Yes

No

Other

Iv#wklv#d#olplwhg0ehqhiw#sodq#+olnh#d#vfkrro#dfflghqw#srolf|,B

Yes

No

26.

Is PERSON 2 pregnant?

Yes

No

a. If yes, how many babies are expected during this pregnancy?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

27.

Does PERSON 2 live with at least one child under 19, and is PERSON 2 the main person taking care of this child?

Yes

No

 

 

 

 

 

 

 

 

 

 

28.

Is PERSON 2 a full-time student?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

29.

Was PERSON 2 in foster care at age 18 or older?

Yes

No

 

 

30. Within the past 6 months, have you used tobacco regularly (4 or more times per week on average excluding religious or ceremonial uses)?

Yes

No

31. Is PERSON 2 a U.S. citizen or U.S. national?

Yes

No

32.Ii#SHUVRQ#5#lvq’w#d#X1V1#flwl}hq#ru#X1V1#qdwlrqdo/ do they have eligible immigration status? (SEE INSTRUCTIONS.)

Yes. Fill in PERSON 2’s document type and ID number below.

 

a. Immigration document type:

 

b. Document ID number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c. Has PERSON 2 lived in the U.S. since 1996?

 

d. Is PERSON 2, or PERSON 2’s spouse or parent, a veteran or an

 

Yes

No

 

active-duty member of the U.S. military?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WKDQNV$#Wklv#lv#doo#zh#qhhg#wr#nqrz#derxw#SHUVRQ#51

NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or call us at 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 and tell the customer service representative the language you need. We’ll get you help at no cost to you. TTY users should call 1-855-889-4325.

FFM-AFFORDABILITY

Page 8 of 9

STEP 3 Uhdg#)#vljq#wklv#dssolfdwlrq1

I’m signing this application under penalty of perjury, which means I’ve given 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 give false and/or untrue information.

I know that under federal law, discrimination isn’t permitted on the basis of race, color, national origin, sex, age, sexual

rulhqwdwlrq/#jhqghu#lghqwlw|/#ru#glvdelolw|1#I#fdq#ioh#d#frpsodlqw#ri#glvfulplqdwlrq#e|#ylvlwlqj#zzz1kkv1jry2rfu2rifh2ioh.

Is anyone applying for an exemption on this application incarcerated (detained or jailed)? Yes No If yes, write the name of the person incarcerated here:

Check here if this person is pending disposition of charges.

We need this information to check your eligibility for an exemption if you choose to apply. We’ll check your answers using information in our electronic databases and databases from the Internal Revenue Service (IRS), Social Security, the Department of Homeland Security, and/or a consumer reporting agency. If the information doesn’t match, we may ask you to send us proof.

Zkdw#vkrxog#I#gr#li#I#wklqn#wkh#uhvxowv#ri#p|#dssolfdwlrq#duh#zurqjB#

If you don’t agree with the results of your exemption application, you can ask for an appeal. Below is important information to consider when requesting an appeal:

The Health Insurance Marketplace must receive your appeal request within 90 days of the date of the notice of the application results.

You can have someone request or participate in your appeal if you want to. That person can be a friend, relative, lawyer, or other individual. Or, you can request and participate in your appeal on your own.

The outcome of an appeal could change the eligibility of other members of your household.

To appeal the results of your exemption application, call 1-800-318-2596. TTY users should call 1-855-889-4325. You can

also mail an appeal request form or your own letter requesting an appeal to Health Insurance Marketplace – Exemption Surfhvvlqj/#465 Industrial Blvd., London, KY 40741.

Vljq#wklv#dssolfdwlrq1#Wkh#shuvrq#zkr#ioohg#rxw#Vwhs#4#vkrxog#vljq#wklv#dssolfdwlrq1#Ii#|rx’uh#dq#dxwkrul}hg#uhsuhvhqwdwlyh#|rx#

may sign here, as long as you have provided the required information listed in Appendix B.

Signature

Date (mm/dd/yyyy)

/

/

STEP 4 Pdlo#frpsohwhg#dssolfdwlrq#dqg#grfxphqwv1

Mail your signed application and documents showing your yearly income (see examples on page 9) to:

Khdowk#Iqvxudqfh#Pdunhwsodfh# #H{hpswlrq#Surfhvvlqj 798#Iqgxvwuldo#Eoyg1

Orqgrq/#N\#73:74

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 or call us at 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 and tell the customer service representative the language you need. We’ll get you help at no cost to you. TTY users should call 1-855-889-4325.

FFM-AFFORDABILITY

Page 9 of 9

STEP 5 Surri#ri#\hduo|#Iqfrph

In order to approve you for this exemption, we need proof of your yearly income for 2014. Examples of documents you can send include:

Wages and tax statement (W-2)

Pay stub

Letter from employer

Self-employment ledger

Frvw#ri#olylqj#dgmxvwphqw#ohwwhu#dqg#rwkhu#ehqhiw#yhulifdwlrq#qrwlfhv

Lease agreement

Copy of a check paid to the household member

Bank or investment fund statement

Document or letter from Social Security Administration (SSA)

Frup#VVD#43<<#Vrfldo#Vhfxulw|#ehqhiwv#vwdwhphqw

Ohwwhu#iurp#jryhuqphqw#djhqf|#iru#xqhpsor|phqw#ehqhiwv

These documents don’t necessarily need to be dated for 2014. For example, you can provide recent pay stubs if you don’t

expect your income to change in 2014. If you expect your income to go up or down in 2014, you can provide other documents, olnh#d#grfxphqw#wkdw#vwdwhv#zkhq#frqwudfw#zrun#zloo#hqg1#Ii#dq|#ri#|rxu#lqfrph#frphv#iurp#iuhhodqfh#zrun/#|rx#fdq#ioo#rxw#d#

self-employment ledger that includes your expected income.

NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or call us at 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 and tell the customer service representative the language you need. We’ll get you help at no cost to you. TTY users should call 1-855-889-4325.

FFM-AFFORDABILITY

APPENDIX A: EXEMPTIONS

Form Approved OMB No. 0938-1191

Khdowk#Fryhudjh#iurp#Mrev#

You DON’T need to answer these questions unless someone in the household is eligible for health coverage from a job. Attach a copy of this

sdjh#iru#hdfk#mre#wkdw#rfhuv#fryhudjh1#

Whoo#xv#derxw#wkh#mre#wkdw#riihuv#fryhudjh1#

Wdnh#wkh#Hpsor|hu#Fryhudjh#Wrro#rq#wkh#qh{w#sdjh#wr#wkh#hpsor|hu#zkr#rfhuv#fryhudjh#wr#khos#|rx#dqvzhu#wkhvh#txhvwlrqv1#\rx#rqo|#qhhg#wr# include this page when you send in your application, not the Employer Coverage Tool.

Employee information

1. Employee name (First, Middle, Last)

2. Employee Social Security number

-

 

 

-

Employer information

3.

Employer name

4.

Employer Identification Number (EIN)

 

 

 

 

 

 

 

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.

Employer address

6.

Employer phone number

 

 

(

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7.

City

8.

State

9. ZIP code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10.

Who can we contact about employee health coverage at this job?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11.

Phone number (if different from above)

12. Email address

(

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13.#Duh#|rx#fxuuhqwo|#holjleoh#iru#fryhudjh#rfhuhg#e|#wklv#hpsor|hu/#ru#zloo#|rx#ehfrph#holjleoh#lq#wkh#qh{w#6#prqwkvB

Yes (Continue)

13a. Ii#|rx’uh#lq#d#zdlwlqj#ru#suredwlrqdu|#shulrg/#zkhq#fdq#|rx#hquroo#lq#fryhudjhB#(mm/dd/yyyy)

/

/

List the names of anyone else who is eligible for coverage from this job.

Name:

 

Name:

 

Name:

 

 

No (Stop here and go to Step 5 in the application)

 

 

Whoo#xv#derxw#wkh#khdowk#sodq#rfhuhg#e|#wklv#hpsor|hu1#

471 Grhv#wkh#hpsor|hu#rfhu#d#khdowk#sodq#wkdw#phhwv#wkh#plqlpxp#ydoxh#vwdqgdug-B## Yes

No

15a. Fru#wkh#orzhvw0frvw#sodq#wkdw#phhwv#wkh#plqlpxp#ydoxh#vwdqgdug-#rfhuhg#only to the employee (don’t include family plans):

If the employer has wellness programs, provide the premium that the employee would pay if they don’t get a discount for wellness programs, including smoking cessation programs.

a. How much would the employee have to pay in premiums for this plan? $

b. How often? Weekly

Every 2 weeks

Twice a month

Once a month

Quarterly Yearly

15b. Fru#wkh#orzhvw0frvw#sodq#wkdw#phhwv#wkh#plqlpxp#ydoxh#vwdqgdug-#rfhuhg#wr#wkh#hpsor|hh#dqg#idplo|#phpehuv#uhtxhvwlqj#dq# exemption (only include family plans for family members that do not already have an exemption): If the employer has wellness programs, provide the premium that the employee would pay if they don’t get a discount for wellness programs, including smoking cessation programs.

a. How much would the employee have to pay in premiums for this plan? $

b. How often? Weekly

Every 2 weeks

Twice a month

Once a month

Quarterly Yearly

16.What change will the employer make for the new plan year (if known)? Employer won’t offer health coverage

Employer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to the

hpsor|hh#wkdw#phhwv#wkh#plqlpxp#ydoxh#vwdqgdug1-#+Suhplxp#vkrxogq’w#uhiohfw#dq|#glvfrxqw#iru#zhooqhvv#surjudpv1#Vhh#txhvwlrq#481,#

a. How much will the employee have to pay in premiums for that plan? $

b. How often? Weekly

Every 2 weeks

Twice a month

Once a month

c. Date of change (mm/dd/yyyy):

 

 

/

 

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Quarterly Yearly

-Dq#hpsor|hu0vsrqvruhg#khdowk#sodq#phhwv#wkh# plqlpxp#ydoxh#vwdqgdug #li#wkh#sodq’v#vkduh#ri#wkh#wrwdo#doorzhg#ehqhiw#frvwv#fryhuhg#e|#wkh#sodq#lv#qr#ohvv#wkdq#

60 percent of such costs (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986).

NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or call us at 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 and tell the customer service representative the language you need. We’ll get you help at no cost to you. TTY users should call 1-855-889-4325.

FFM-AFFORDABILITY

HPSOR\HU#FRYHUDJH#WRRO=#H[HPSWIRQV#

OMB No. 0938-1191

 

Form Approved

Use this tool to help answer questions in your Marketplace application, Appendix A. That part of the application asks about any employer health coverage that you’re eligible for (even if it’s from another person’s job, like a parent or a spouse). The information in the numbered boxes below match the boxes in Appendix A. For example, you can use the answer to question 14 on this page to answer question 14 on Appendix A.

Zulwh#|rxu#qdph#dqg#Vrfldo#Vhfxulw|#qxpehu#lq#er{hv#4#dqg#5#dqg#dvn#wkh#hpsor|hu#wr#ioo#rxw#wkh#uhvw#ri#wkh#irup1#Frpsohwh#rqh#wrro# iru#hdfk#hpsor|hu#wkdw#rfhuv#khdowk#fryhudjh#wkdw#|rx’uh#holjleoh#iru1#

EMPLOYEE information

The employee#qhhgv#wr#ioo#rxw#wklv#vhfwlrq1

1. Employee name (First, Middle, Last)

2. Employee Social Security Number

-

 

 

-

EMPLOYER information

Ask the employer for this information.

3.

Employer name

 

 

 

 

 

 

 

 

 

 

4.

Employer Identification Number (EIN)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.

Employer address (the Marketplace will send notices to this address)

6.

Employer phone number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7.

City

 

 

 

 

 

 

 

 

 

 

8.

State

9. ZIP code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10.

Who can we contact about employee health coverage at this job?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11.

Phone number (if different from above)

12. Email address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13.#Iv#wkh#hpsor|hh#fxuuhqwo|#holjleoh#iru#fryhudjh#rfhuhg#e|#wklv#hpsor|hu/#ru#zloo#wkh#hpsor|hh#eh#holjleoh#lq#wkh#qh{w#6#prqwkvB

Yes (Go to question 13a.)

13a. If the employee is not eligible today, including as a result of a waiting or probationary period, when is the employee eligible for

coverage?(mm/dd/yyyy) (Go to next question) No (STOP and return this form to employee)

Tell us about the health planrfhuhg#e|#wklv#employer.

Grhv#wkh#hpsor|hu#rfhu#d#khdowk#sodq#wkdw#fryhuv#dq#hpsor|hh’v#vsrxvh#ru#ghshqghqwB#

Yes. Which people? Spouse

Dependent(s)

No

(Go to question 14)

 

 

471 Grhv#wkh#hpsor|hu#rfhu#d#khdowk#sodq#wkdw#phhwv#wkh#plqlpxp#ydoxh#vwdqgdug-B

 

Yes (Go to question 15)

No (STOP and return this form to employee)

15a. Fru#wkh#orzhvw0frvw#sodq#wkdw#phhwv#wkh#plqlpxp#ydoxh#vwdqgdug-#rfhuhg#only to the employee (don’t include family plans):

If the employer has wellness programs, provide the premium that the employee would pay if they don’t get a discount for wellness programs, including smoking cessation programs.

a. How much would the employee have to pay in premiums for this plan? $

b. How often? Weekly

Every 2 weeks

Twice a month

Once a month

Quarterly Yearly

15b. Fru#wkh#orzhvw0frvw#sodq#wkdw#phhwv#wkh#plqlpxp#ydoxh#vwdqgdug-#rfhuhg#wr#wkh#hpsor|hh#dqg#idplo|#phpehuv#uhtxhvwlqj#dq# exemption (only include family plans for family members that do not already have an exemption): If the employer has wellness programs, provide the premium that the employee would pay if they don’t get a discount for wellness programs, including smoking cessation programs.

a. How much would the employee have to pay in premiums for this plan? $

b. How often? Weekly

Every 2 weeks

Twice a month

Once a month

Quarterly Yearly

If the plan year will end soon and you know that the health plans offered will change, go to question 16. If you don’t know, STOP and return this form to employee.

16. What change will the employer make for the new plan year?

Employer won’t offer health coverage

Employer will start offering health coverage to employees or change the premium for the lowest-cost plan that meets the minimum

ydoxh#vwdqgdug-#dqg#lv#dydlodeoh#wr#wkh#hpsor|hh#rqo|1#+Suhplxp#vkrxogq’w#uhiohfw#dq|#glvfrxqw#iru#zhooqhvv#surjudpv1#Vhh#txhvwlrq#481,#

a. How much will the employee have to pay in premiums for that plan? $

b. How often?

Weekly

Every 2 weeks

Twice a month

Once a month

c. Date of change (mm/dd/yyyy):

 

 

/

 

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Quarterly

Yearly

-Dq#hpsor|hu0vsrqvruhg#khdowk#sodq#phhwv#wkh# plqlpxp#ydoxh#vwdqgdug #li#wkh#sodq’v#vkduh#ri#wkh#wrwdo#doorzhg#ehqhiw#frvwv#fryhuhg#e|#wkh#sodq#lv#qr#ohvv#wkdq#

60 percent of such costs (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986).

NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or call us at 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 and tell the customer service representative the language you need. We’ll get you help at no cost to you. TTY users should call 1-855-889-4325.

FFM-AFFORDABILITY

DSSHQGI[#E#

OMB No. 0938-1191

 

Form Approved

Dvvlvwdqfh#zlwk#frpsohwlqj#wklv#dssolfdwlrq#

\rx#fdq#fkrrvh#dq#dxwkrul}hg#uhsuhvhqwdwlyh1#

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 your application on your behalf. This person is called an “authorized representative.” If you ever need to change your authorized representative, contact the Marketplace. If you’re a legally appointed representative for someone on this application, submit proof with the application.

1. Name of authorized representative (First name, Middle name, Last name)

2.Address

4.City

7.Phone number

 

 

 

3.

Apartment or suite number

5. State

6.

ZIP code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

8.Organization name

9.ID number (if applicable)

By signing, you allow this person to sign your application, get official information about this application, and act for you on all future matters related to this application.

10. Your signature

11. Date (mm/dd/yyyy)

/ /

Iru#fhuwlihg#dssolfdwlrq#frxqvhoruv/#qdyljdwruv/#djhqwv/#dqg#eurnhuv#rqo|1##

Frpsohwh#wklv#vhfwlrq#li#|rx’uh#d#fhuwlihg#dssolfdwlrq#frxqvhoru/#qdyljdwru/#djhqw/#ru#eurnhu#ioolqj#rxw#wklv#dssolfdwlrq#iru#

somebody else.

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

/

/

2.First name, Middle name, Last name, & Suffix

3.Organization name

4. ID number (if applicable)

5. Agents/Brokers only: NPN number

NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or call us at 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 and tell the customer service representative the language you need. We’ll get you help at no cost to you. TTY users should call 1-855-889-4325.

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