Every person needs to have health coverage or make a payment on their
federal income tax return called the “Shared Responsibility Payment.” Some people are exempt from making the Shared Responsibility payment. This application is for a category of exemptions called "hardships" available only through the Marketplace.
Hardship number Category Required documentation
1 You were homeless. None
2 You were evicted or were facing eviction or
foreclosure. Eviction or foreclosure notice. The document must show that the event happened
in this calendar year or up to two calendar years prior.
3 You received a shut-off notice from a utility company. Shut off notice from an electric, water/sewer, or gas utility company that says service has been or will be shut off. The document must show that the shut off happened in this calendar year or up to two calendar years prior.
4 You recently experienced domestic violence. None
5 You experienced the death of a close family
member. Death certificate, death notice from newspaper, funeral service program, funeral
expenses, coroner's report, military notification of death, or other official notice
of death. The document must show that the death happened in this calendar
year or up to two calendar years prior.
6 You experienced a fire, flood, or other
natural human-caused disaster that caused
substantial damage to your property.
Police or fire report, insurance claim, or other document from a government
agency or news source about the disaster. The document must show that the
event happened in this calendar year or up to two calendar years prior.
7 You filed for bankruptcy.
Bankruptcy filing document from a court or other legal authority. The document
must show that the bankruptcy happened in this calendar year or up to two
calendar years prior.
8 You had medical expenses you couldn't pay. One or more medical bills. The bill(s) must be for this calendar year or up to two calendar years prior.
9 You experienced unexpected increases in
necessary expenses due to caring for an ill,
disabled, or aging family member.
Receipts for bills or services related to a family member's care, like medical bills,
home care services, or transportation receipts. The receipts must be from this
calendar year or up to two calendar years prior.
10 A child you expected to claim as a tax dependent has been denied coverage in
Medicaid and the Children’s Health Insurance Program (CHIP), and another
person is required by court order to provide health coverage to the child.
Court order that covers the time period for which you want the exemption for the
child and copy of eligibility notice that shows the child was denied Medicaid and
CHIP coverage from your state. The Medicaid/CHIP document must show
eligibility determination for this calendar year or up to two calendar years prior.
11 As a result of a Health Insurance Marketplace or state-based Marketplace
appeals decision, you're eligible for: 1) enrollment in a qualified health plan through the Marketplace; 2) lower costs on your monthly premiums; or 3) cost-sharing reductions for a time period when you weren't enrolled in a Marketplace plan. Notice of appeal from the Health Insurance Marketplace or your state-based Marketplace. The appeals notice must be from this calendar year or up to two calendar years prior.
12 An adult in your tax household was determined ineligible for Medicaid because your state did NOT expand eligibility for Medicaid under the Affordable Care Act. None. This exemption is available only for the most recent calendar year.
13 You got a notice from a health insurance plan you purchased on the individual market
(not job based coverage) saying your policy was cancelled because it didn't meet Affordable Care Act requirements and you considered other plans unaffordable. This category is no longer available for 2017 and future years. Notice of cancellation from your insurance company must be dated after January 1, 2015 and before October 31, 2016. This exemption is not available if your coverage was cancelled after October 31, 2016.
14 You experienced a hardship NOT listed in categories 1-13 that kept you from getting
health insurance. A very limited number of other hardships qualify. Include any documentation
that explains why you’re requesting a hardship exemption NOT listed in categories 1-13. The documentation must show that the hardship happened within this calendar year or up to two calendar years prior.