State of NJ - Department of the Treasury

Instructions: Fill out this form completely if your family did not have health insurance for all or part of 2023.

1. Put in the number that corresponds to your Filing Status:

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. NJ State Average Bronze Premium

7. 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.

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

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:

Enter number of months dependent 6 had qualifying health insurance:

Enter number of months dependent 7 had qualifying health insurance:

Enter number of months dependent 8 had qualifying health insurance:

Enter number of months dependent 9 had qualifying health insurance:

Enter number of months dependent 10 had qualifying health insurance:

Enter number of months dependent 11 had qualifying health insurance:

Enter number of months dependent 12 had qualifying health insurance:

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

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

State Shared Responsibility Payment

Official Site of The State of New Jersey