Taxpayer's Name: | ||||
Tax Year: |
Region:
48 states
Alaska
Hawaii
State expanded Medicaid? Yes No State has ACA Basic Health Program? Yes No | |||
Filing Status: |
TP 65 or older in
SP 65 or older in |
Filing Threshold: 100% Fed Poverty Line: 138% Fed Poverty Line: 400% Fed Poverty Line: |
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Number of dependents: |
Amount | Location | TP & SP | Depend 1 | Depend 2 | Depend 3 | Depend 4 | Depend 5 |
AGI | |||||||
Tax-exempt interest | |||||||
Social Security Income | |||||||
Taxable Social Security | |||||||
Foreign Income | |||||||
Form 1040 cap gain/loss | Form 1040 line 13 | } | |||||
Adjustments to income | Form 1040 line 36 | ||||||
Main Home Sale exclusion | Sched D & Forms 8949 | ||||||
Schedule D gains | Sched D & Forms 8949 | ||||||
Business expenses/losses | Sched C, lines 28 + 30 | ||||||
Comments | Total dependent MAGI
For use in TaxSlayer 1095A reconciliation: |
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Household Income (MAGI) | (for Form 8965) | Used for affordability test | |||||
Gross Income | Used for affordability test | ||||||
Household Income (MAGI) | (for Form 8962) | Used for PTC/APTC calc | |||||
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Total premiums paid through salary reduction and excluded from income |
Adjusted Annual Income =
Affordability threshold at % = |
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NOTE: This amount is compared with insurance premium costs to determine affordability in the next worksheet. |
Taxpayer | Spouse | Depend 1 | Depend 2 | Depend 3 | Depend 4 | Depend 5 | |
Exempt by another code, MEC or GOV? | |||||||
1. Lowest cost self-only policy offered by employer |
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2. Lowest cost family policy offered by employer |
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It appears there are two differently-costed family plan offers by employers.
Is the Spouse included in the Taxpayer's family plan? Yes No Is the Taxpayer included in the Spouse's family plan? Yes No | |||||||
3. Amount from Marketplace Coverage Affordability Worksheet line 12 |
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Use exemption code: | |||||||
January | |||||||
February | |||||||
March | |||||||
April | |||||||
May | |||||||
June | |||||||
July | |||||||
August | |||||||
September | |||||||
October | |||||||
November | |||||||
December | |||||||
ANNUALIZED COST FOR PERIOD: | |||||||
PERCENT OF HOUSEHOLD INCOME: |
Marketplace Coverage Affordability Worksheet |
To get Bronze and Silver plan costs, use:
https://www.healthcare.gov/tax-tool/ or your state exchange: ⇐ Enter your state exchange URL or, as a last resort, http://www.healthpocket.com | ||
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1. Monthly lowest cost Bronze plan
: |
Lowest Bronze plan premium amount using 's age . | ||
2. Household income: | Household income without untaxed Social Security | ||
3. Nontaxable Social Security: | Includes nontaxed Social Security for all tax family members | ||
4. Add lines 2 + 3: | Household income with untaxed Social Security | ||
5. Fed Poverty Line: | |||
6. Divide line 4 by line 5: | |||
7. Multiply line 6 by 100 and look up: . |
Value is from col 2 of the Form 8962 Instructions for line 7. | ||
8. Multiply line 4 by line 7: | TP's annual contribution amount before PTC | ||
9. Divide line 8 by 12: | TP's monthly contribution amount before PTC | ||
10. Monthly second lowest cost Silver plan : |
Second lowest Silver plan premium amount using 's age . | ||
11. Subtract line 9 from line 10: | Maximum PTC amount allowed (but limited by the Bronze plan cost) | ||
12. Subtract line 11 from line 1: | Cost to the taxpayer after PTC is applied | ||
13. Return to the Affordability Worksheet above and click the "Click to test" button. |