Transcription of CAUTION: NOT FOR FILING - IRS tax forms
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CAUTION: NOT FOR FILING - IRS tax forms
CAUTION: NOT FOR FILING . form 1095-A is provided here for informational purposes only. Health Insurance Marketplaces use form 1095-A to report information on enrollments in a qualified health plan in the individual market through the Marketplace. As the form is to be completed by the Marketplaces, individuals cannot complete and use form 1095-A available on Individuals receiving a completed form 1095-A from the Health Insurance Marketplace will use the information received on the form and the guidance in the instructions to assist them in FILING an accurate tax return. form 1095-A Health Insurance Marketplace Statement VOID OMB No. 1545-2232. Department of the Treasury Internal Revenue Service Go Do not attach to your tax return. Keep for your records. to for instructions and the latest information. CORRECTED 2017. 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.)
policy was terminated by your insurance company due to nonpayment of premiums for 1 or more months, then a -0- will appear in this column for the months, regardless of whether advance credit payments were made for these months.
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