Federal Free Printable 2016 Form 1095-A for 2017 Federal Health Insurance Marketplace Statement

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Health Insurance Marketplace Statement
2016 Form 1095-A

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 IRS.gov. 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 Department of the Treasury Internal Revenue Service Part I Health Insurance Marketplace Statement ▶ Do VOID not attach to your tax return. Keep for your records. about Form 1095-A and its separate instructions is at www.irs.gov/form1095a. OMB No. 1545-2232 CORRECTED ▶ Information 2016 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.) 13 City or town 14 State or province 15 Country and ZIP or foreign postal code Part II Covered Individuals A. Covered individual name B. Covered individual SSN C. Covered individual date of birth D. Coverage start date E. Coverage termination date 16 17 18 19 20 Part III Coverage Information Month A. Monthly enrollment premiums B. Monthly second lowest cost silver plan (SLCSP) premium C. Monthly advance payment of premium tax credit 21 January 22 February 23 March 24 April 25 May 26 June 27 July 28 August 29 September 30 October 31 November 32 December 33 Annual Totals For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. Cat. No. 60703Q Form 1095-A (2016) Form 1095-A (2016) Instructions for Recipient You received this Form 1095-A because you or a family member enrolled in health insurance coverage through the Health Insurance Marketplace. This Form 1095-A provides information you need to complete Form 8962, Premium Tax Credit (PTC). You must complete Form 8962 and file it with your tax return if any amount other than zero is shown in Part III, Column C, of this Form 1095-A (meaning that you received premium assistance through advance credit payments) or if you want to take the premium tax credit. The filing requirement applies whether or not you're otherwise required to file a tax return. The Marketplace has also reported the information on this form to the IRS. If you or your family members enrolled at the Marketplace in more than one qualified health plan policy, you will receive a Form 1095-A for each policy. Check the information on this form carefully. Please contact your Marketplace if you have questions concerning its accuracy. If you or your family members were enrolled in a Marketplace catastrophic health plan or separate dental policy, you aren't entitled to take a premium tax credit for this coverage when you file your return, even if you received a Form 1095-A for this coverage. For additional information related to Form 1095-A, go to www.irs.gov/affordable-care-act/individuals-and-families/healthinsurance-marketplace-statements. VOID box. If the "VOID" box is checked at the top of the form, you previously received a Form 1095-A for the policy described in Part I. That Form 1095-A was sent in error. You shouldn't have received a Form 1095-A for this policy. Don't use the information on this or the previously received Form 1095-A to figure your premium tax credit on Form 8962. CORRECTED box. If the "CORRECTED" box is checked at the top of the form, use the information on this Form 1095-A to figure the premium tax credit and reconcile any advance credit payments on Form 8962. Don't use the information on the original Form 1095-A you received for this policy. Part I. Recipient Information, lines 1–15. Part I reports information about you, the insurance company that issued your policy, and the Marketplace where you enrolled in the coverage. Line 1. This line identifies the state where you enrolled in coverage through the Marketplace. Line 2. This line is the policy number assigned by the Marketplace to identify the policy in which you enrolled. If you are completing Part IV of Form 8962, enter this number on line 30, 31, 32, or 33, box a. Line 3. This is the name of the insurance company that issued your policy. Line 4. You are the recipient because you are the person the Marketplace identified at enrollment who is expected to file a tax return and who, if qualified, would take the premium tax credit for the year of coverage. Line 5. This is your social security number. For your protection, this form may show only the last four digits. However, the Marketplace has reported your complete social security number to the IRS. Line 6. A date of birth will be entered if there is no social security number on line 5. Lines 7, 8, and 9. Information about your spouse will be entered only if advance credit payments were made for your coverage. The date of birth will be entered on line 9 only if line 8 is blank. Lines 10 and 11. These are the starting and ending dates of the policy. Lines 12 through 15. Your address is entered on these lines. Part II. Covered Individuals, lines 16–20. Part II reports information about each individual who is covered under your policy. This information includes the name, social security number, date of birth, and the starting and ending dates of coverage for each covered individual. For each line, a date of birth is reported in column C only if an SSN isn't entered in column B. Page 2 If advance credit payments are made, only the individuals for whom you attested the intention to claim a personal exemption deduction (yourself, spouse, and dependents) to the Marketplace at enrollment will be listed on Form 1095-A. If you attested to the Marketplace at enrollment that one or more of the individuals who enrolled in the plan aren't individuals for whom you intend to claim a personal exemption deduction on your tax return, those individuals won't be listed on your Form 1095-A. For example, if you indicated to the Marketplace at enrollment that an individual enrolling in the policy is your adult child for whom you won't claim a personal exemption deduction, that child will receive a separate Form 1095-A and won't be listed in Part II on your Form 1095-A. If advance credit payments weren't made and you didn't identify at enrollment the individuals for whom you intended to claim a personal exemption deduction, Form 1095-A will list all enrolled individuals in Part II on your Form 1095-A. Part II also tells the IRS the months that the individuals identified are covered by health insurance and therefore have satisfied the individual shared responsibility provision. If there are more than 5 individuals covered by a policy, you will receive one or more additional Forms 1095-A that continue Part II. Part III. Coverage Information, lines 21–33. Part III reports information about your insurance coverage that you will need to complete Form 8962 to reconcile advance credit payments or to take the premium tax credit when you file your return. Column A. This column is the monthly premiums for the plan in which you or family members were enrolled, including premiums that you paid and premiums that were paid through advance payments of the premium tax credit. If you or a family member enrolled in a separate dental plan with pediatric benefits, this column includes the portion of the dental plan premiums for the pediatric benefits. If your plan covered benefits that aren't essential health benefits, such as adult dental or vision benefits, the amount in this column will be reduced by the premiums for the nonessential benefits. If the policy was terminated by your insurance company due to nonpayment of premiums for one or more months, then a -0- will appear in this column for these months regardless of whether advance credit payments were made for these months. Column B. This column is the monthly premium for the second lowest cost silver plan (SLCSP) that the Marketplace has determined applies to members of your family enrolled in the coverage. The applicable SLCSP premium is used to compute your monthly advance credit payments and the premium tax credit you take on your return. See the Instructions for Form 8962, Part II, on how to use the information in this column or how to complete Form 8962 if there is no information entered. If the policy was terminated by your insurance company due to nonpayment of premiums for one 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. Column C. This column is the monthly amount of advance credit payments that were made to your insurance company on your behalf to pay for all or part of the premiums for your coverage. If this is the only column in Part III that is filled in with an amount other than zero for a month, it means your policy was terminated by your insurance company due to nonpayment of premiums, and you aren't entitled to take the premium tax credit for that month when you file your tax return. You still must reconcile the entire advance payment that was paid on your behalf for that month using Form 8962. No information will be entered in this column if no advance credit payments were made. Lines 21–33. The Marketplace will report the amounts in columns A, B, and C on lines 21–32 for each month and enter the totals on line 33. Use this information to complete Form 8962, line 11 or lines 12–23.
Extracted from PDF file 2016-federal-form-1095-a.pdf, last modified September 2016

More about the Federal Form 1095-A Corporate Income Tax TY 2016

We last updated the Health Insurance Marketplace Statement in May 2017, so this is the latest version of Form 1095-A, fully updated for tax year 2016. You can download or print current or past-year PDFs of Form 1095-A directly from TaxFormFinder. You can print other Federal tax forms here.

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Form 941 Employer's Quarterly Federal Tax Return
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Form Sources:

The Internal Revenue Service usually releases income tax forms for the current tax year between October and January, although changes to some forms can come even later. We last updated Federal Form 1095-A from the Internal Revenue Service in May 2017.

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About the Corporate Income Tax

The IRS and most states require corporations to file an income tax return, with the exact filing requirements depending on the type of company.

Sole proprietorships or disregarded entities like LLCs are filed on Schedule C (or the state equivalent) of the owner's personal income tax return, flow-through entities like S Corporations or Partnerships are generally required to file an informational return equivilent to the IRS Form 1120S or Form 1065, and full corporations must file the equivalent of federal Form 1120 (and, unlike flow-through corporations, are often subject to a corporate tax liability).

Additional forms are available for a wide variety of specific entities and transactions including fiduciaries, nonprofits, and companies involved in other specific types of business.

Historical Past-Year Versions of Federal Form 1095-A

We have a total of three past-year versions of Form 1095-A in the TaxFormFinder archives, including for the previous tax year. Download past year versions of this tax form as PDFs here:


2016 Form 1095-A

2016 Form 1095-A

Health Insurance Marketplace Statement 2015 Form 1095-A

2015 Form 1095-A

Health Insurance Marketplace Statement 2014 Form 1095-A

2014 Form 1095-A


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