Determine Your 2020 Shared Responsibility Payment
Instructions: Fill out this form completely if your family did not have health insurance for all or part of 2020.
Fill out for any family member who had health insurance coverage for only part of the year.
- Do not include a figure for any family member who had insurance for nine or more consecutive months.
- Enter the total months for all family members in the appropriate prompt. Example: A family has two spouses over age 18 and one dependent child under age 18. Family members had coverage only in November and December. Spouse 1: 2 months. Spouse 2: 2 months. Total for line (a): 4. Dependent Child: 2 months Total for line (b): 2
State Shared Responsibility Payment