Transcription of 2021 California Form 3853 Health Coverage Exemptions and ...
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2021 California Form 3853 Health Coverage Exemptions and ...
8661213 FTB 3853 2021 Side 1 For Privacy Notice, get FTB 1131 Coverage Exemptions and Individual Shared Responsibility PenaltyTAXABLE YEAR2021 California FORM3853 Attach to your California Form 540, Form 540NR, or Form 540 (s) as shown on your California tax returnSSN or ITINPart I Applicable Household Members. List all members of your applicable household whether or not they have an exemption or an Exemption Certificate Number (ECN) granted by the Marketplace. See NameInitialSSNDate of Birth (mm/dd/yyyy)Modified AGILast NameECN 1 ECN 2 ECN 32 First NameInitialSSNDate of Birth (mm/dd/yyyy)Modified AGILast NameECN 1 ECN 2 ECN 33 First NameInitialSSNDate of Birth (mm/dd/yyyy)Modified AGILast NameECN 1 ECN 2 ECN 34 First NameInitialSSNDate of Birth (mm/dd/yyyy)Modified AGILast NameECN 1 ECN 2 ECN 35 First NameInitialSSNDate of Birth (mm/dd/yyyy)Modified AGILast NameECN 1 ECN 2 ECN
CALIFORNIA FORM. 3853 . Attach to your California Form 540, Form 540NR, or Form 540 2EZ. Name(s) as shown on your California tax return SSN or ITIN. ... 2021 California Form 3853 Health Coverage Exemptions and Individual Shared Responsibility Penalty Author: webmaster@ftb.ca.gov Subject:
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