Form 1095-A - Health Insurance Marketplace Statement (2015)

Form 1095-A
2015
Department of the Treasury
Internal Revenue Service
Health Insurance Marketplace Statement
â–¶
Information about Form 1095-A and its separate instructions
is at www.irs.gov/form1095a.
OMB No. 1545-2232
VOID
CORRECTED
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.
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 Totals
For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.
Cat. No. 60703Q
Form 1095-A (2015)
Page 1/2
Free Download

Form 1095-A - Health Insurance Marketplace Statement (2015) PDF

Favor this template? Just fancy it by voting!
  •  
  •  
  •  
  •  
  •  
(0 Votes)
0.0
Related Forms
  •  
  •  
  •  
  •  
  •  
5 Page(s) | 1697 Views | 4 Downloads
  •  
  •  
  •  
  •  
  •  
6 Page(s) | 2082 Views | 9 Downloads
  •  
  •  
  •  
  •  
  •  
2 Page(s) | 1001 Views | 12 Downloads
  •  
  •  
  •  
  •  
  •  
8 Page(s) | 3338 Views | 28 Downloads
  •  
  •  
  •  
  •  
  •  
38 Page(s) | 6636 Views | 31 Downloads