Form 1095-A- Health Insurance Marketplace Statement

Health Insurance Premium Tax Credit

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1545-2232 can be found here:

Documents and Forms

Document Name Document Type
Form 1095-A Form 1095-A- Health Insurance Marketplace Statement Form
Instr for Form 1095-A.pdf Instruction
1095-A Health Insurance Marketplace Statement Form 1095-A.pdf Form

Information Collection (IC) Details

IC Title:	Form 1095-A- Health Insurance Marketplace Statement	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1095-A	Health Insurance Marketplace Statement	Form 1095-A.pdf		Yes	Yes	Fillable Fileable
Instruction			Instr for Form 1095-A.pdf		Yes	No	Printable Only

Line of Business: General Government

Subfunction: Taxation Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 15	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 50 %

	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	2,000,000	2,000,000
Annual IC Time Burden (Hours)	11,250	11,250
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.