Application for Exemption from the Shared Responsibility Payment for Individuals who Experience Hardships - Form 11/2014

Sep 19, 2026

Application instructions for requesting an exemption from the federal shared responsibility payment when hardship prevents health coverage. Explains who may use the form, including hardship experienced by the applicant or tax household, and notes potential eligibility for catastrophic coverage. Lists required supporting documents, Social Security Numbers (if available), and household information, and explains how the information is used and secured under law. Provides assistance channels online, phone, in person, and multilingual support details.

LanguageEnglish

CategoryForms

FormatPDF

Pages7

Reading Time3 min

AccessFree to download

Application overview

Who can use this application

What you need to apply

Why we ask for this information

Get help with this application

Hardship categories and documentation

Application for Exemption from the Shared Responsibility Payment for Individuals who Experience Hardships 11/2014 Form Approved OMB No. 0938-1190 Use this application to apply for an exemption from the shared responsibility payment • Every person needs to have health coverage or make a payment on their federal income tax return called the “shared responsibility payment.” • Some people are exempt from making this payment. This application is for one category of exemption. You may apply for certain other categories of exemptions when you file your federal income tax return. • You don’t need to apply for an exemption if you’re not going to file a federal income tax return. If you’re not sure you’ll file a tax return, you may want to apply for an exemption anyway. Who can use this application? • Use this application if you and/or anyone in your tax household have experienced a hardship that keeps you from getting health coverage. See page 1 for the list of hardships. • If you get a hardship exemption, you may qualify for catastrophic coverage. • You can use one single application to ask for this exemption for more than one person in your tax household. What you need to apply • Documents that support your claim of hardship (see page 1 for descriptions of which documents are needed for each hardship exemption.) The document(s) you submit must show dates from the same time period you’re requesting this exemption for. If you can’t obtain the documents, call the Health Insurance Marketplace Call Center at 1-800-318-2596. TTY users should call 1-855-889-4325. • Social Security Numbers (SSNs), if you have them. • Information about people in your tax household. Why do we ask for this information? We ask for Social Security Numbers and other information to make sure your exemption is counted when you file your federal income tax return. We’ll keep all the information you give private and secure, as required by law. To view the Privacy Act Statement, go to [HealthCare.gov](HealthCare.gov) or see instructions. Get help with this application • [Online: ](Online: HealthCare.gov/exemptions)[HealthCare.gov/exemptions](Online: HealthCare.gov/exemptions). • Phone: Call the Marketplace Call Center at 1-800-318-2596. TTY users should call 1-855-889-4325. • In person: There may be counselors in your area who can help. Visit [HealthCare.gov](HealthCare.gov), or call the Marketplace Call Center at 1-800-318-2596 for more information. • En Español: Llame a nuestro centro de ayuda gratis al 1-800-318-2596. • Other languages: If you need help in a language other than English, call 1-800-318-2596 and tell the customer service representative the language you need. We’ll get you help at no cost to you. [NEED HELP WITH YOUR APPLICATION?](NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov)[ Visit](NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov)[ ](NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov)[HealthCare.gov](NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov), or call us at 1-800-318-2596. Para obtener una copia de este formulario en Español, llame 1-800-318-2596. If you need help in a language other than English, call 1-800-318-2596 and tell the customer service representative the language you need. We’ll get you help at no cost to you. TTY users should call 1-855-889-4325. HARDSHIP Hardship Categories and Documentation Page 1 of 5 Look at the hardship categories and the required documents listed below to see if you qualify for a hardship exemption. | Hardship number | Category | Required documentation
(Send COPIES of one of the documents listed below foryour hardship.) | | --- | --- | --- | | 1 | You were homeless. | None. | | 2 | You were evicted in the past 6 months or were facing eviction or foreclosure. | Eviction or foreclosure notice. The date of the notice must be within the last 6 months. | | 3 | You received a shut-off notice from a utility company. | Shut-off notice

FAQs

Who can use this hardship exemption application?

You can use it if you and/or someone in your tax household experienced a hardship that prevents you from getting health coverage. It covers hardships listed in the hardship category table.

What documents are required to support a hardship claim?

You must submit copies of the required documents for the specific hardship category you qualify under. The documents must include dates from the same time period you are requesting the exemption for.

What information is needed besides hardship documentation?

If you have them, include Social Security Numbers. Also provide information about people in your tax household to support the exemption request.

Sep 19, 2026

Upload by River Wang