2018 Form 8965 - Internal Revenue Service
If you and/or a member of your tax household are claiming an exemption on your return, complete Part III.
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Health Coverage Exemptions
Department of the Treasury Internal Revenue Service
Attach to Form 1040. Go to www.irs.gov/Form8965 for instructions and the latest information.
OMB No. 1545-0074
Attachment Sequence No. 75
Name as shown on return
Your social security numberComplete this form if you have a Marketplace-granted coverage exemption or you are claiming a coverage exemption on your return.
Marketplace-Granted Coverage Exemptions for Individuals. If you and/or a member of your tax household
(a) Name of Individual
(c) Exemption Certificate Number
Coverage Exemptions Claimed on Your Return for Your Household7 If you are claiming a coverage exemption because your household income or gross income is below the filing threshold, check here ..................................
Coverage Exemptions Claimed on Your Return for Individuals. If you and/or a member of your tax
(c) Exemption Type
(d) Full Year
For Privacy Act and Paperwork Reduction Act Notice, see your tax return instructions.
Cat. No. 37787G
Form 8965 (2018)