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Notice to Employees: Requirements of the Affordable Care Act As of January 1, 2014, the Affordable Care Act (ACA) requires you to have health insurance for yourself and your dependents. Some people
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This form is used to report information about individuals who don't have health coverage and request exemptions from the requirement to have coverage.
Individuals who don't have health coverage and are seeking an exemption from the coverage requirement are required to file this form.
The form can be filled out online or submitted by mail, providing information about the individual's circumstances and why they are seeking an exemption.
The purpose of this form is to grant individuals exemptions from the requirement to have health coverage based on specific circumstances.
Information such as personal details, income, reasons for not having coverage, and supporting documentation must be reported on this form.
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