1095-A

    1095-A


    Health Insurance Marketplace Statement

    • Do not attach to your tax return. Keep for your records.
    • Go to www.irs.gov/Form1095A for instructions and the latest information



    Part I Recipient Information
















    Part II Covered Individuals

    16.
    17.
    18.
    19.
    20.

    Part III Coverage Information

    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 Total