Fillable Form 8965: Health Coverage Exemptions (IRS)

Fill Online, Printable, Fillable, Blank Form 8965: Health Coverage Exemptions (IRS) Form

Use Fill to complete blank online IRS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Form 8965: Health Coverage Exemptions (IRS)

On average this form takes 29 minutes to complete

The Form 8965: Health Coverage Exemptions (IRS) form is 1 page long and contains:

  • 0 signatures
  • 1 check-box
  • 116 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your IRS forms online.

The Internal Revenue Service (IRS) is a government agency responsible for collecting taxes and administering the federal statutory tax laws of the United States. The IRS provide tax assistance to taxpayers and pursue and resolve fraudulent tax filings.

BROWSE IRS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Form 8965
2016
Health Coverage Exemptions
Department of the Treasury
Internal Revenue Service
▶
Attach to Form 1040, Form 1040A, or Form 1040EZ.
▶
Information about Form 8965 and its separate instructions is at www.irs.gov/form8965.
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 (2016)
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Form 8965: Health Coverage Exemptions (IRS)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 18 March 2022

Message

View Audit Log
Print With Audit Log
Duplicate Document