2014 ACA WORKSHEET
Monthly Insurance Coverage Certification
Household Member
All Year
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sept
Oct
Nov
Dec
Please provide the following information:
1. List each member of your household and indicate the months that they had health insurance coverage.
2. Health Insurance company:
3. Health Insurance Policy Number:
4. Sign and date:
Taxpayer
Date
Spouse
Date

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