1095-A | Health Insurance

1095-A

Health Insurance Marketplace Statement

Do not attach to your tax return. Keep for your records.
Go to www.irs.gov/Form1095A for instructions and the latest information

Email:

Full Name:

Part I Recipient Information

1 Marketplace identifier

2 Marketplace-assigned policy number

3 Policy issuer’s name

4 Recipient’s name

5 Recipient’s SSN

6 Recipient’s date of birth

7 Recipient’s spouse’s name

8 Recipient’s spouse’s SSN

9 Recipient’s spouse’s date of birth

10 Policy start date

11 Policy termination date

12 Street address (including apartment no.)

13 City or town

14 State or province

15 Country and ZIP or foreign postal code

Part II Covered Individuals

A. Covered individual name	B. Covered individual SSN	C. Covered individual date of birth	D. Coverage start date E	E. Coverage termination date
16.
17.
18.
19.
20.

Part III Coverage Information

Month	A. Monthly enrollment premiums	B. Monthly second lowest cost silver plan (SLCSP) premium	C. Monthly advance payment of premium tax credit
21 January
22 February
23 March
24 April
25 May
26 June
27 July
28 August
29 September
30 October
31 November
32 December
33 Annual Total

Friendly Tax Services

Contact Us

Address :
1010 N Central Ave. Suite 415 Glendale, CA 91202
Call Us :
(323)451-5768
(866)542-9551
E-mail Us :
Contact@LAPremierTax.com

Call us

1095-A | Health Insurance

1095-A

Health Insurance Marketplace Statement

Part I Recipient Information

Part II Covered Individuals

Part III Coverage Information

Like this:

Friendly Tax Services

Quick Links

Contact Us

Call us

1095-A | Health Insurance

1095-A

Health Insurance Marketplace Statement

Part I Recipient Information

Part II Covered Individuals

Part III Coverage Information

Share this:

Like this:

Friendly Tax Services

Quick Links

Contact Us