TAXABLE YEAR
2021
California Health Insurance
Marketplace Statement
CALIFORNIA FORM
3895
VOID
CORRECTED
Recipient’s name Initial Last name Suffix Recipient’s SSN Recipient’s date of birth
Spouse’s first name Initial Last name Suffix Spouse’s SSN Spouse’s date of birth
Address (apt./ste., room, PO box, or PMB no.)
City State
ZIP code
Marketplace identifier Marketplace-assigned policy number Policy issuer’s name
Policy start date Policy
termination date
Repayment cap may not apply
Part I Covered Individuals
(a)
Covered individual name
(b)
Covered
individual SSN
(c)
Covered individual
date of birth
(d)
Coverage
start date
(e)
Coverage
termination date
First name Last name
1
2
3
4
5
Part II Coverage Information
Month
(a)
Monthly enrollment premiums
(b)
Monthly second lowest cost
silver plan (SLCSP) premium
(c)
Monthly advance payment of
premium assistance subsidy
6
January
7 February
8 March
9 April
10 May
11 June
12 July
13 August
14 September
15 October
16 November
17 December
18 Annual Totals
For Privacy Notice, get FTB 1131 EN-SP.
