Fillable Form 8965: Health Coverage Exemptions (IRS)

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Form 8965: Health Coverage Exemptions (IRS)

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Form 8965
2017
Health Coverage Exemptions
Department of the Treasury
Internal Revenue Service
▶
Attach to Form 1040, Form 1040A, or Form 1040EZ.
▶
Go to www.irs.gov/Form8965 for instructions and the latest information.
OMB No. 1545-0074
Attachment
Sequence No.
75
Name as shown on return Your social security number
Complete this form if you have a Marketplace-granted coverage exemption or you are claiming a coverage exemption
on your return.
Part I
Marketplace-Granted Coverage Exemptions for Individuals. If you and/or a member of your tax household
have an exemption granted by the Marketplace, complete Part I.
(a)
Name of Individual
(b)
SSN
(c)
Exemption Certificate Number
1
2
3
4
5
6
Part II Coverage Exemptions Claimed on Your Return for Your Household
7
If you are claiming a coverage exemption because your household income or gross income is below the filing threshold,
check here . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Part III
Coverage Exemptions Claimed on Your Return for Individuals. If you and/or a member of your tax
household are claiming an exemption on your return, complete Part III.
(a)
Name of Individual
(b)
SSN
(c)
Exemption
Type
(d)
Full
Year
(e)
Jan
(f)
Feb
(g)
Mar
(h)
Apr
(i)
May
(j)
June
(k)
July
(l)
Aug
(m)
Sept
(n)
Oct
(o)
Nov
(p)
Dec
8
9
10
11
12
13
For Privacy Act and Paperwork Reduction Act Notice, see your tax return instructions.
Cat. No. 37787G
Form 8965 (2017)
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Form 8965: Health Coverage Exemptions (IRS)

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Completed 22 January 2021

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