Form 1095-A Health Insurance Marketplace Statement

Version A, Cycle 25

Form

1095-A

Department of the Treasury
Internal Revenue Service

Health Insurance Marketplace Statement
▶ Information

about Form 1095-A and its separate instructions
is at www.irs.gov/form1095a.

OMB No. 1545-2232

CORRECTED

2014

Recipient Information

Part I

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

Internal Use Only
Draft As Of
September 25, 2014

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

Coverage Household

A. Covered Individual Name

16
17
18

B. Covered Individual SSN

C. Covered Individual
Date of Birth

D. Covered Individual
Start Date

E. Covered Individual
Termination Date

19
20

Part III

Household Information
Month

A. Monthly Premium Amount

B. Monthly Premium Amount of Second
Lowest Cost Silver Plan (SLCSP)

C. Monthly Advance Payment of
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)

Version A, Cycle 25
Page 2

Form 1095-A (2014)

Instructions for Recipient
You received this Form 1095-A because you or a family member
enrolled in health insurance coverage through the Health
Insurance Marketplace. This Form 1095-A provides information
you need to complete Form 8962, Premium Tax Credit (PTC).
You must complete Form 8962 and file it with your tax return if
you want to claim the premium tax credit or if you received
premium assistance through advance credit payments (whether
or not you otherwise are required to file a tax return). The
Marketplace has also reported this information to the IRS. If you
or your family members enrolled at the Marketplace in more
than one qualified health plan policy, you will receive a
Form 1095-A for each policy.

number, date of birth (only if no social security number is
entered in column B), and the start and ending dates of
coverage for each covered individual.
If you or your family members enrolled at the Marketplace in a
policy with one or more individuals who are not your spouse or
dependent and advance credit payments were made, the
information reported on Form 1095-A applies only to the
individuals for whom you attested to the Marketplace at
enrollment the intention to claim a personal exemption
deduction on your tax return (yourself, spouse, and
dependents). For example, if you indicated to the Marketplace
at enrollment that an individual enrolling in the policy is your
adult child for whom you will not claim a personal exemption
deduction, that child will receive a separate Form 1095-A and
will not be listed in Part II on your Form 1095-A.

Internal Use Only
Draft As Of
September 25, 2014

Part I. Recipient Information, lines 1–15. Part I reports
information about you, the insurance company that issued your
policy, and the Marketplace where you enrolled in the coverage.
Line 1. This line identifies the state where you enrolled in
coverage through the Marketplace.

Line 2. The Marketplace-assigned policy number is the number
the Marketplace uses to identify the policy in which you
enrolled. If you are completing Part 4 of Form 8962, enter this
number on line 30, 31, 32, or 33, box a.
Line 3. This is the name of the insurance company that issued
your policy.
Line 4. You are the recipient because you are the person the
Marketplace identified at enrollment who is expected to file a
tax return and who, if qualified, would claim the premium tax
credit for the year of coverage.

Line 5. This is your social security number. For your protection,
this form may show only the last four digits. However, the
Marketplace has reported your complete social security number
to the IRS.
Line 6. A date of birth will be entered if there is no social
security number on line 5.
Lines 7, 8, and 9. Information about your spouse will be entered
only if advance credit payments were made for your coverage.
The date of birth will be entered on line 9 only if line 8 is blank.
Lines 10 and 11. These are the start and ending dates of the
policy.
Lines 12 through 15. Your address is entered on these lines.
Part II. Coverage Household, lines 16–20. Part II reports
information about each individual who is covered under your
policy. This information includes the name, social security

Part II also tells the IRS the months that the individuals
identified are covered by health insurance and therefore have
satisfied the individual shared responsibility provision.
If there are more than 5 individuals covered by a policy you
will receive one or more additional Forms 1095-A that continue
Part II.
Part III. Household Information, lines 21–33. Part III reports
information about your insurance coverage that you will need to
complete Form 8962 to claim the premium tax credit and
reconcile advance credit payments.
Column A. This column is the monthly premium amount for the
policy in which you enrolled.
Column B. This column is the monthly premium amount for the
second lowest cost silver plan (SLCSP) that the Marketplace
has determined applies to members of your family enrolled in
the coverage. The premium for the applicable SLCSP is used to
compute your monthly advance credit payments and the
premium tax credit you claim on your return. If no information is
entered in this column, see the Instructions for Form 8962, Part
2, Premium Tax Credit Claim and Reconciliation of Advance
Payment of Premium Tax Credit.
Column C. This column is the monthly amount of advance
credit payments that were made to your insurance company to
pay for all or part of the premiums for your coverage. No
information will be entered in this column if no advance credit
payments were made.
Lines 21–33. The Marketplace will report the amounts in
columns A, B, and C on lines 21–32 for each month and enter
the totals on line 33. Use this information to complete
Form 8962, line 11 or lines 12–23.