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Department of the Treasury Internal Revenue Service
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Health Insurance Marketplace Statement
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Do not attach to your tax return. Keep for your records.
Go to www.irs.gov/Form1095A for instructions and the latest information.
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OMB No. 1545-2232
2023
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Part I Recipient Information
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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 ___
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Part II Covered Individuals
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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
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Part III Coverage Information
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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
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For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.
Cat. No. 60703Q
Form 1095-A (2023)
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GENERAL LIST OF POSITIONS.
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Pos. No. 1. Sent. O.K.d Appt. written.
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1932
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