Name
Street Address 1
Street Address 2
City, State ZIP Code
Month ##, ####
Account ID: AC############
We are sending you an important tax document
We are sending you this document because you or a family member enrolled in health
insurance coverage with financial assistance through NY State of Health for all or part of 2014.
This financial assistance was in the form of advance payments of the premium tax credit
(APTC). The Internal Revenue Service requires individuals or families who receive APTC to file
an income tax return and attach IRS Form 8962, Premium Tax Credit (PTC). Form 8962 is
available from the IRS at www.irs.gov
. Along with this letter, you will find Form 1095-A, Health
Insurance Marketplace Statement. This form will help you complete Form 8962. You will receive
one Form 1095-A for each plan your or a member of your tax family enrolled in during 2014.
The IRS defines the tax family in the instructions for Form 8962.
IT IS IMPORTANT FOR YOU TO KNOW
…What Form 1095-A is.
Form 1095-A is a tax document like a W-2 or a form from the 1099 series that you will use to
complete your 2014 federal tax return. Please keep this form for your records. It provides most
of the information you need to complete Form 8962. You must file Form 8962 with your 2014 tax
return if one of the following applies to you or your family:
• APTC was paid for you or for someone else in your tax family.
• APTC was paid for someone for whom you told us you would claim a personal
exemption, if no one else claims a personal exemption for him or her.
The Form 1095-A is only issued for qualified health plans purchased through the Marketplace at
the Bronze, Silver, Gold and Platinum levels. The Form 1095-A is not issued for Catastrophic
plans or for Medicaid or Child Health Plus plans because consumers may not claim PTC for
these plans.
IT IS IMPORTANT FOR YOU TO KNOW
…Who to contact for help.
If you have questions about Form 1095-A or the PTC, visit
www.info.nystateofhealth.ny.gov/taxcredits
or call Community Health Advocates’ Helpline at 1-
888-614-5400.
If you think we made a mistake on your Form 1095-A, call NY State of Health at 1-855-766-
7860.
If you have questions about Form 8962 or other tax-related questions, visit www.irs.gov
.
