Information Collection

Form 1095-A- Health Insurance Marketplace Statement

IC 213666 under ICR 201711-1545-006 · OMB 1545-2232.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1545-2232 can be found here:

Documents and Forms

Document Name Document Type
Form 1095-A Form 1095-A- Health Insurance Marketplace Statement Form
Instr 1095-A--2017.pdf Instruction
1095-A Health Insurance Marketplace Statement Form 1095-A--2017.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Form 1095-A- Health Insurance Marketplace Statement	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 26 CFR 1.36B–5

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1095-A	Health Insurance Marketplace Statement	Form 1095-A--2017.pdf		Yes	Yes	Fillable Fileable
Instruction			Instr 1095-A--2017.pdf		Yes	No	Printable Only

Line of Business: General Government

Subfunction: Taxation Management

Privacy Act System of Records
Title: IRS 24.030- Individual Master File, IRS 24.046-Customer Account Data Engine Business Master File, and IRS 34.037- Audit Trail and Security Records System	FR Citation: 80 FR 54064

Number of Respondents: 15	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 50 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	3,250,000	1,250,000	2,000,000
Annual IC Time Burden (Hours)	16,250	5,000	11,250
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.