2021 California Form 3853 Health Coverage Exemptions and ...

1 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 36 First NameInitialSSNDate of Birth (mm/dd/yyyy)Modified AGILast NameECN 1 ECN 2 ECN 37 First NameInitialSSNDate of Birth (mm/dd/yyyy)

2 Modified AGILast NameECN 1 ECN 2 ECN 38 First NameInitialSSNDate of Birth (mm/dd/yyyy)Modified AGILast NameECN 1 ECN 2 ECN 39 First NameInitialSSNDate of Birth (mm/dd/yyyy)Modified AGILast NameECN 1 ECN 2 ECN 310 First NameInitialSSNDate of Birth (mm/dd/yyyy)Modified AGILast NameECN 1 ECN 2 ECN 311 First NameInitialSSNDate of Birth (mm/dd/yyyy)Modified AGILast NameECN 1 ECN 2 ECN 312 First NameInitialSSNDate of Birth (mm/dd/yyyy)Modified AGILast NameECN 1 ECN 2 ECN 3 Part II Coverage Exemption Claimed on Your Tax Return for Your Household1 If you are claiming a Coverage exemption because your applicable household income or gross income is below the filing threshold, check the box here.

3 See instructions.. 8662213 Side 2 FTB 3853 2021 Part IV Individual Shared Responsibility Penalty1 Your Individual Shared Responsibility Penalty. Enter on Form 540, line 92; Form 540NR, line 91; or Form 540 2EZ, line 27. See 1. Part III Coverage and Exemptions Claimed on Your Tax Return for Individuals. If you and/or a member of your applicable household are reporting any Coverage or are claiming Exemptions for the tax year, complete Part III. See and Exemption Codes(a)Full-year(b)Jan(c)Feb(d)Mar(e)Ap r(f)May(g)June(h)July(i)Aug(j)Sept(k)Oct (l)Nov(m)Dec1 First NameInitialLast Name2 First NameInitialLast Name3 First NameInitialLast Name4 First NameInitialLast Name5 First NameInitialLast Name6 First NameInitialLast Name7 First NameInitialLast Name8 First NameInitialLast Name9 First NameInitialLast Name10 First NameInitialLast Name11 First NameInitialLast Name12 First NameInitialLast Nam