Welcome to the Affordable Care Act Worksheet for
the 2019 tax year. Please make sure this worksheet is
complete and all requested material is provided.
IMPORTANT QUESTIONS
Taxpayer Spouse
Please Answer All Questions
Yes No Yes No
Did you receive Form 1095-A, 1095-B, or 1095-C? If yes, please provide a copy.
If no, did you maintain health insurance at any point during the year?
Are you entitled to claim dependents?
If yes, were the dependents covered by health insurance at any point during the year?
Were there any gaps or lack of coverage in the year for you or any dependents?
If yes, was there more than one gap?
Was any gap less than 3 months? If yes, the gap can qualify for a short coverage gap exception.
If you had gaps that do not meet the short coverage exception, are you exempt because you were:
Part of a recognized religious sect?
Part of a health care sharing ministry?
Not lawfully present in the U.S.?
Incarcerated?
A member of an Indian Tribe?
Could not aff ord coverage?
Qualifi ed for a hardship exemption?
If yes, please provide Exemption Certifi cate Number (ECN)?
Tax returns without ECNs are rejected.
Application for Exemption found at HealthCare.gov https://www.healthcare.gov/fees-exemptions/apply-for-exemption/
FLIGHTAX P.O. Box 139 Cicero, IN 46034 317-984-5812 V 800-951-8879 F www.fl ightax.com
PERSONAL DATA
(Please Print)
First Name M.I. Last Name (as on your SS Card)
Taxpayer:
Spouse:
