Irs 1095A Form PDF Details

The intricacies of the IRS 1095-A form, an essential document for individuals who enrolled in health insurance through the Health Insurance Marketplace, reflect the intersections of healthcare, taxation, and policy. This form plays a pivotal role in the annual tax filing process, capturing information about the insurance policy, the policyholder, and any dependents covered by the policy. Its primary purpose is to assist taxpayers in reconciling advance payments of the premium tax credit and to claim the premium tax credit on their tax return. The details provided in the form—ranging from the policy start and termination dates, to monthly premiums and advance payment amounts—underscore the nuanced interface between individual healthcare decisions and their tax implications. Notably, the form is instrumental for those seeking to utilize premium tax credits to make health insurance more affordable, serving as a bridge between the marketplace's administrative data and the taxpayer's obligations and entitlements under the Tax Code. As such, understanding the 1095-A form is crucial for individuals aiming to accurately complete their tax returns, particularly in light of the Affordable Care Act's provisions that intertwine health coverage with tax liabilities and benefits. The caution against using draft forms underscores the importance of accuracy and timeliness in tax filing, reflecting a broader context where tax administration and healthcare provisioning intersect.

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Form NameIrs 1095A Form
Form Length3 pages
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Avg. time to fill out45 sec
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Form 1095-A

Department of the Treasury Internal Revenue Service

Health Insurance Marketplace Statement

▶ Information about Form 1095-A and its separate instructions

CORRECTED

is at www.irs.gov/form1095a.

 

OMB No. 1545-2232

2014

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

 

DRAFT

AS OF

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

 

 

OCTOBER

1, 2014

Part II Coverage Household

16

 

 

DO

NOT

FILE

 

 

 

A. Covered Individual Name

B. Covered Individual SSN

C. Covered Individual

D. Covered Individual

E. Covered Individual

 

 

 

 

 

 

 

Date of Birth

 

Start Date

Termination Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

17

 

 

 

 

 

 

 

 

 

 

18

 

 

 

 

 

 

 

 

 

 

19

 

 

 

 

 

 

 

 

 

 

20

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Part III

Household Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Month

 

A. Monthly Premium Amount

B. Monthly Premium Amount of Second

C. Monthly Advance Payment of

 

 

 

 

 

Lowest Cost Silver Plan (SLCSP)

 

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 (2014)

Form 1095-A (2014)

 

Page 2

 

 

Instructions for Recipient

number, date of birth (only if no social security number is

entered in column B), and the start and ending dates of

 

You received this Form 1095-A because you or a family member

coverage for each covered individual.

enrolled in health insurance coverage through the Health

If you or your family members enrolled at the Marketplace in a

Insurance Marketplace. This Form 1095-A provides information

policy with one or more individuals who are not your spouse or

you need to complete Form 8962, Premium Tax Credit (PTC).

dependent and advance credit payments were made, the

You must complete Form 8962 and file it with your tax return if

information reported on Form 1095-A applies only to the

you want to claim the premium tax credit or if you received

individuals for whom you attested to the Marketplace at

premium assistance through advance credit payments (whether

enrollment the intention to claim a personal exemption

or not you otherwise are required to file a tax return). The

deduction on your tax return (yourself, spouse, and

Marketplace has also reported this information to the IRS. If you

dependents). For example, if you indicated to the Marketplace

or your family members enrolled at the Marketplace in more

enrollment that an individual enrolling in the policy is your

DRAFT atAS OF

than one qualified health plan policy, you will receive a

adult child for whom you will not claim a personal exemption

Form 1095-A for each policy.

deduction, that child will receive a separate Form 1095-A and

 

Part I. Recipient Information, lines 1–15. Part I reports

will not be listed in Part II on your Form 1095-A.

information about you, the insurance company that issued your

Part II also tells the IRS the months that the individuals

policy, and the Marketplace where you enrolled in the coverage.

identified are covered by health insurance and therefore have

Line 1. This line identifies the state where you enrolled in

satisfied the individual shared responsibility provision.

OCTOBER

1, 2014

coverage through the Marketplace.

If there are more than 5 individuals covered by a policy you

 

Line 2. The Marketplace-assigned policy number is the number

will receive one or more additional Forms 1095-A that continue

the Marketplace uses to identify the policy in which you

Part II.

 

enrolled. If you are completing Part 4 of Form 8962, enter this

Part III. Household Information, lines 21–33. Part III reports

number on line 30, 31, 32, or 33, box a.

information about your insurance coverage that you will need to

 

 

complete Form 8962 to claim the premium tax credit and

Line 3. This is the nameDOof the insurance companyNOTthat issued

FILE

your policy.

reconcile advance credit payments.

Line 4. You are the recipient because you are the person the

Column A. This column is the monthly premium amount for the

Marketplace identified at enrollment who is expected to file a

policy in which you enrolled.

tax return and who, if qualified, would claim the premium tax

Column B. This column is the monthly premium amount for the

credit for the year of coverage.

second lowest cost silver plan (SLCSP) that the Marketplace

 

Line 5. This is your social security number. For your protection,

has determined applies to members of your family enrolled in

this form may show only the last four digits. However, the

the coverage. The premium for the applicable SLCSP is used to

Marketplace has reported your complete social security number

compute your monthly advance credit payments and the

to the IRS.

premium tax credit you claim on your return. If no information is

Line 6. A date of birth will be entered if there is no social

entered in this column, see the Instructions for Form 8962, Part

2, Premium Tax Credit Claim and Reconciliation of Advance

security number on line 5.

Payment of Premium Tax Credit.

 

Lines 7, 8, and 9. Information about your spouse will be entered

Column C. This column is the monthly amount of advance

only if advance credit payments were made for your coverage.

credit payments that were made to your insurance company to

The date of birth will be entered on line 9 only if line 8 is blank.

pay for all or part of the premiums for your coverage. No

 

Lines 10 and 11. These are the start and ending dates of the

information will be entered in this column if no advance credit

policy.

payments were made.

Lines 12 through 15. Your address is entered on these lines.

Lines 21–33. The Marketplace will report the amounts in

Part II. Coverage Household, lines 16–20. Part II reports

columns A, B, and C on lines 21–32 for each month and enter

 

 

information about each individual who is covered under your

the totals on line 33. Use this information to complete

Form 8962, line 11 or lines 12–23.

policy. This information includes the name, social security

 

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1095a fillable writing process explained (part 1)

2. After filling out the last section, go to the next stage and complete all required particulars in these fields - If you wish you can submit, instructions or publications on, page on IRSgov We cannot respond, volume we receive but we will, we may not be able to consider, and revision of the product.

1095a fillable completion process clarified (step 2)

3. The following step is mostly about Form A, Department of the Treasury, Health Insurance Marketplace, Information about Form A and its, CORRECTED, is at wwwirsgovforma, OMB No, Part I Recipient Information, Marketplace identifier, Marketplaceassigned policy number, Policy issuers name, Recipients name, Recipients spouses name, Policy start date, and City or town - complete all of these blanks.

1095a fillable completion process outlined (step 3)

When it comes to Policy issuers name and City or town, ensure you do everything right here. These could be the key ones in the document.

4. You're ready to fill in the next section! In this case you will have all of these Part III Household Information, Month, A Monthly Premium Amount B Monthly, C Monthly Advance Payment of, Lowest Cost Silver Plan SLCSP, Premium Tax Credit, January, February, March, April, May, June, July, August, and September form blanks to fill out.

Writing part 4 in 1095a fillable

5. The document must be finalized by filling out this area. Below you will see a detailed set of blanks that must be filled in with correct details to allow your document usage to be accomplished: October, November, December, Annual Totals, For Privacy Act and Paperwork, Cat No Q, and Form A.

1095a fillable conclusion process clarified (stage 5)

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