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Division of Taxation

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.

  1. Single
  2. Married/Filing Joint
  3. Married/Filing Separate
  4. Head Of Household
  5. Qualifying Widow(er)







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

18 Years of age or older

Under 18 years of age





State Shared Responsibility Payment 
$

Last Updated: Monday, 12/07/20