Printable blank Form 1095-A

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What is form 1095-A? 

Form 1095-A is the form for declaring the cost of health insurance and federal subsidy you receive. This subsidy or Premium Tax Credit (PTC) is necessary to make the cost of healthcare cheaper.   

What I need form 1095-A for? 

  • To provide the government with information about federal subsidy and health insurance;
  • If you bought a plan on the health marketplace, the healthcare coverage would be cheaper for you;
  • Note that PTC is paid by the government in advance each month, therefore be sure to fill the form on time. 

Filling out form 1095-A

The form has three sections:

  • In the first section, you need to provide your personal information, such as Marketplace identifier, name, the name of your spouse, address, policy start date, and so on;
  • The second section is dedicated to covered individuals. Write down the covered individual’s name, their SSN, date of birth, coverage start and termination dates;
  • In the third part, there’s more information on coverage. Here you need to fill the following information for each month: enrollment premium, second lowest-cost silver plan premium or the advance payment of premium tax credit. 

Organizations that work with form 1095-A

Health insurance providers. 

Related Form 1095-A Tax Documents

IRS Form 1095-A Resources

Relevant to 1095-A form 2021

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