Form Dss 8118 PDF Details

In order to claim an exemption from the Affordable Care Act's (ACA) individual shared responsibility provision, taxpayers must file Form 8118. This form is used to indicate that the taxpayer has been granted an exemption from the requirement to maintain minimum essential coverage. The ACA requires taxpayers who do not have health insurance coverage to pay a penalty known as the shared responsibility payment. Form 8118 should be filed with your federal income tax return if you are claiming one of the following exemptions: -Members of a religious sect which objects to insurance; -Member or adherent of a recognized religious denomination which opposes accepting government benefits; -Insured individuals covered by a faith-based health care sharing ministry; -Taxpayers who are uninsured for more than three months of the year; -Individuals not lawfully present in the United States.

QuestionAnswer
Form NameForm Dss 8118
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesdss 8118 ia certification utilities moratorium form

Form Preview Example

TO:

 

 

 

CERTIFICATION UTILITIES MORATORIUM

 

(Electric or Natural Gas Company)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Address)

 

 

 

 

 

 

 

 

 

 

 

DATE:

 

 

(City)

(State)

(Zip)

 

 

 

 

SUBJECT:

Request for Continuation of Services According to the N.C. Utilities Commission Order of

 

 

November 14, 1979, Amending Rules R12-10 & R12-11.

I request that my electric/gas services be continued through March 31,

 

 

 

I according to Rules R12-10 and R12-1 1.

1. I certify that a member(s) of my household is either elderly (65 years of age and older) or disabled:

Elderly:

Name of Household Member

 

Age

 

 

 

Name of Household Member

 

Age

If disabled person in household, give following information:

Name of Household Member

Age

Description of Disability

Has he been certified as disabled by a governmental agency?

Yes

 

No If yes, list name of agency:

2.I certify that I cannot pay my electric/gas bill in full. Also, I certify that I cannot pay my past and current electric/ gas bill in six monthly payments. After paying my other monthly bills, I do not have the necessary resources.

3.I certify that my household meets the eligibility requirements of the Low Income Energy Assistance Program.

CERTIFICATION

I certify that the above information is true. I declare that to the best of my knowledge I am the only person in my

household who has applied for a continuation of services through March 31, I as provided in the November 14, 1979, order of the N.C. Utilities Commission. I am aware that I can be penalized by fine and/or imprisonment for making false statements. Further, I am aware that while I may be eligible, the completion of this application does not entitle me to any assistance under the Low Income Energy Assistance Program.

Applicant's Name (Print or Type)

(Date)

(Applicant's Signature)

Account Number (if known)

Service Address

I hereby certify that based on the information provided me by the above named applicant, that he is eligible for the requested assistance.

Distribution:

Original to Utility Company 1 Copy to Applicant County File Copy

(Local Administering Agency)

(Certifying Agent)

DSS-8118 (2/93)

(Date)

Economic Independence

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1. The Form Dss 8118 will require certain information to be inserted. Make sure the next fields are completed:

Learn how to fill in Form Dss 8118 part 1

2. Once your current task is complete, take the next step – fill out all of these fields - Name of Household Member, Description of Disability, Has he been certified as disabled, Yes, No If yes list name of agency, Age, I certify that I cannot pay my, I certify that my household meets, CERTIFICATION, I certify that the above, Applicants Name Print or Type, Date, Applicants Signature, and Account Number if known with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

I certify that I cannot pay my, No If yes list name of agency, and Description of Disability in Form Dss 8118

It's easy to make errors when completing your I certify that I cannot pay my, thus make sure that you take a second look before you decide to send it in.

3. The following segment is about I hereby certify that based on the, Distribution Original to Utility, DSS Economic Independence, Local Administering Agency, Certifying Agent, and Date - fill in all these empty form fields.

DSS Economic Independence, Local Administering Agency, and Certifying Agent of Form Dss 8118

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