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State of Nebraska INVITATION TO Return to: State Purchasing Bureau 1526 K Street, Suite 130 Lincoln, Nebraska 68508CONTRACT DatePage8/14/17Solicitation Number Opening Date and Time BuyerTelephone:
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To fill out form 5655, follow these steps:
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Start by entering your name, address, and contact information in the designated fields at the top of the form.
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Next, provide the tax year and the employer identification number (EIN) of the business for which you are filing the form.
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Indicate your filing status by checking the appropriate box (e.g., Single, Married filing jointly, etc.).
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Report any advanced payment of premium tax credit that you received by filling in the corresponding details.
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Add up all your health coverage exemptions, if applicable, and enter the total amount.
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Calculate the shared responsibility payment by following the instructions provided on the form.
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Determine if you are eligible for an exemption from the shared responsibility payment and provide the necessary information.
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Complete the signature section by signing and dating the form.
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Attach any supporting documents as required.
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Make a copy of the filled-out form for your records and submit the original form to the appropriate tax authority.
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Form 5655 is needed by individuals who are required to report their health coverage exemptions and calculate the shared responsibility payment (penalty) for not having minimum essential health coverage.
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