Fenn 1095-A Health Insurance Marketplace Statement ❑ VOID OMB No. 1545-2232
Department of the TiteSuly
internal Revenue Senile!
► Do not attach to your tax return. Keep for your records.
PO Go to tinvwdrs.gov/Fonn1095.4 for Instructions and the latest Information.
❑ CORRECTED 2017
Part 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 0 Recipient's spouse's date of birth
10 Poky start date 11 Policy termination date 12 Street address (including apartment no.)
13 City or town 14 State at province 15 Country and ZIP or foreign postal code
Part II Covered Individuals
A. Covered indmdual name 8. Covered indvidual SSN C. Covered individual D. Coverage start date E. Coverage tormation date
date of birth
18
17
18
19
20
Part III Coverage Information
Month A. Monthly enrollment premiums B. Monthly second lowest cost silver C. Monthly advance payment of
plan (SLCSP) premium premium tax credit
21 January
22 February
23 March
24 April
25 May
26 June
27 July
28
29 September
30 October
31 November
32 December
33 Annual Totals
For Privacy Act and Paperwork Reduction Act Notice, see separate Instructions. Form 1095-A (2017)
EFTA01222588