2020 Form 3895 California Health Insurance Marketplace ...

FTB 3895 (NEW 2020)8651203 TAXABLE YEAR 2020 California Health Insurance Marketplace StatementCALIFORNIA form 3895 VOIDCORRECTEDR ecipient s nameInitialLast nameSuffixRecipient s SSNR ecipient s date of birthSpouse s first nameInitialLast nameSuffixSpouse s SSNS pouse s date of birthAddress ( , room, PO box, or PMB no.)CityStateZIP codeMarketplace identifierMarketplace-assigned policy numberPolicy issuer s namePolicy start datePolicy termination dateRepayment cap may not applyPart I Covered Individuals(a) Covered individual name(b) Covered individual SSN(c) Covered individual date of birth(d) Coverage start date(e) Coverage termination dateFirst nameLast name12345 Part II Coverage InformationMonth(a) Monthly enrollment premiums(b) Monthly second lowest cost silver plan (SLCSP) premium(c) Monthly advance payment of premium assistance subsidy6 January7 February8 March9 April10 May11 June12 July13 August14 September15 October16 November17 December18 Annual TotalsFor Privacy Notice, get FTB 1131 ENG/SP.

TAXABLE YEAR CALIFORNIA FORM 2020 California Health Insurance Marketplace Statement 3895 VOID CORRECTED Recipient’s name Initial Last name Suffix Recipient’s SSN Recipient’s date of birth Spouse’s first name Initial Last name Suffix Spouse’s SSN Spouse’s date of birth Address (apt./ste., room, PO box, or PMB no.) City State ZIP code

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Transcription of 2020 Form 3895 California Health Insurance Marketplace ...

1 FTB 3895 (NEW 2020)8651203 TAXABLE YEAR 2020 California Health Insurance Marketplace StatementCALIFORNIA form 3895 VOIDCORRECTEDR ecipient s nameInitialLast nameSuffixRecipient s SSNR ecipient s date of birthSpouse s first nameInitialLast nameSuffixSpouse s SSNS pouse s date of birthAddress ( , room, PO box, or PMB no.)CityStateZIP codeMarketplace identifierMarketplace-assigned policy numberPolicy issuer s namePolicy start datePolicy termination dateRepayment cap may not applyPart I Covered Individuals(a) Covered individual name(b) Covered individual SSN(c) Covered individual date of birth(d) Coverage start date(e) Coverage termination dateFirst nameLast name12345 Part II Coverage InformationMonth(a) Monthly enrollment premiums(b) Monthly second lowest cost silver plan (SLCSP) premium(c) Monthly advance payment of premium assistance subsidy6 January7 February8 March9 April10 May11 June12 July13 August14 September15 October16 November17 December18 Annual TotalsFor Privacy Notice, get FTB 1131 ENG/SP.