EFTA01222587.pdf

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) EFTA01222587