Note: This application is for the year 2020 and later. To apply for an exemption for an earlier year, go to HealthCare.gov/exemptions.
About This Application
- Starting in 2020, people who live in California must have health coverage that meets state requirements.
- If you do not have this coverage, you must make an “Individual Shared Responsibility Payment” on your state income tax return, unless you have an exemption. An exemption excuses you from the coverage requirement.
- If you, and all of your tax dependents, are not required to file a state income tax return, you do not need to apply for an exemption. If you are not sure if you are required to file, you may want to apply for an exemption anyway.
- If you have a general hardship that prevents you from getting health coverage, use this exemption application.
- If you have had a hardship, we encourage you to first apply for health care coverage through Coveredca.com to see if free or low-cost health coverage is available to you. This application can still help for months you did not have coverage.
Who Should Apply
- The primary tax filer should complete this application and list everyone they claim on their state tax return. If someone in the household files taxes separately, they must fill out their own application.
- If you get married or have a child and they want this exemption, you need to apply for the exemption again with your spouse and/or child. All people in your tax household must have their own Exemption Certificate Number (ECN) for use on your state tax return.
What You Will Need To Apply
- Date of birth for all household members on this application.
- Social Security numbers (SSNs) or Individual Taxpayer Identification Numbers (ITINs)
- Proof to support your claim of hardship, or a written explanation.
Why We Ask For This Information
- We ask for SSN and other information to determine your eligibility for an exemption and to help make sure that if you get an exemption, it’s applied correctly on your state income tax return
- To read the Privacy Act Statement, go to CoveredCA.com/privacy/.