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Affordable Care Act (Obama Care) Information

[__CLICK HERE if you've completed the Affordable Care Act (Obamacare) Form previously and want to continue to the rest of the Forms__]

Name:  Tax Year: 

Please answer with Yes or No ...

1)  Did everyone on your Tax Return have Health Insurance for the full 12 months in 2015?   
2)  Was Everyone’s Health Insurance paid through an Employer?
3)  Did you make any payments through the Market Place?  
4)  Was anyone on:   Medicaid, Medicare, Chips, Other?
If "Yes" for #4 above, please list below:  Who and Which Plan

5)  Do you have a qualified Health Insurance Exemption?

If "Yes" for #5 above, please list What Kind of Exemption

6)  Would you prefer to NOT compute Health Insurance Shared Responsibility Payment? *

* The IRS will contact you directly and this will likely slow down your refund!

7)  Did any of the DEPENDENTS claimed on your tax return WORK during the year?

If "Yes" for #7 above - We will need to see or prepare their tax return

Notes/Comments:


The undersigned guarantees that all information provided to Gregory's Tax and Bookkeeping Service for the purpose of preparing income tax returns is true and accurate.  This also constitutes a contract with Gregory's Tax and Bookkeeping Service for the purpose of preparing income tax returns and the undersigned agrees to be responsible for all charges incurred in that process.


 

Signature ___________________________________________            Date _____________

 

 

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