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Division of Taxation

Determining the State Shared Responsibility Payment

Shaded boxes require no entry by user.


2. Number of individuals over the age of 18 (including filers):

3. Number of individuals under the age of 18:

4. Total number of family members:


6. Filing Threshold:

7. Taxable income less filing threshold:

8. Income Percentage Amount: Calculation is 2.5% times Line 7, times number of months of residency, divided by 12.

9. State Average Bronze Premium:

10. Enter the number of full months you resided in NJ:

Fill out for any family member who had health insurance coverage for only part of the year. Use the adjacent box for each individual according to their age


18 Years of age or older

Under 18 years of age

Enter number of months you had qualifying health insurance:

Enter number of months your spouse/partner had qualifying health insurance:

Enter number of months dependent 1 had qualifying health insurance:

Enter number of months dependent 2 had qualifying health insurance:

Enter number of months dependent 3 had qualifying health insurance:

Enter number of months dependent 4 had qualifying health insurance:

Enter number of months dependent 5 had qualifying health insurance:

(a) Total number of months all individuals over 18 had qualifying health insurance coverage:

(b) Total number of months all individuals under 18 had qualifying health insurance coverage:


State Shared Responsibility Payment
$
Calculation for tax household that had no health coverage or did not qualify for exemption
This section is limited to part-year or full year residents who had no health coverage during the entire year.
11. Multiply $695 by all those who were 18 or over 11.
12. Multiply $347.5 by all those who were under 1812.
13. Add line 11 and line 12 then multiply by percentage of months as resident (line 10 divided by 12)13.
14. Flat Rate Amount. Enter lesser of line 3 or $2,08514.
15. Enter Income Percentage Amount from line 815.
16. Enter greater of Flat Rate Amount or Income Percentage Amount16.
17. Enter the amount listed for the size of your tax household17.
18. Shared Responsibility Payment. Enter the lesser of line 16 or line 1718.
Calculation for tax household with some health coverage (or exemption) and part-year residents
This section is limited to part-year or full year residents who had health coverage for part of the year.
19. Multiply number of individuals 18 or older by line 1019.
20. Total number of months all those 18 or over had coverage20.
21. Total number of months all those 18 or over did not have coverage21.
22. Multiply line 20 by $57.9222.
23. Multiply number of individuals under 18 by line 1023.
24. Total number of months all those under 18 had coverage24.
25. Total number of months all those under 18 did not have coverage25.
26. Multiply line 20 by $28.9626.
27. Add lines 22 and 2627.
28. Flat Rate Amount. Enter lesser of line 27 or $2,08528.
29. Enter Income Percentage Amount from line 829.
30. Multiply total number of family members by number of months family resided in New Jersey 30.
31. Total number of months all individuals had health insurance coverage. Add lines (a) and (b)31.
32. Total number of months all individuals had no insurance coverage (line 30 - line 31)32.
33. Percentage of months without coverage33.
34. Income Percentage Amount. Line 29 x line 3334.
35. Enter greater of Flat Rate Amount or Income Percentage Amount35.
36. Enter amount for the size of tax household36.
37. Shared Responsibility Payment. Enter the lesser of line 31 or line 3237.

Last Updated: Friday, 01/31/20