[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-302200-105":3,"detail-sidebar-cat-1-en-105":80,"doc-detail-302200-en":126},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":73,"head_meta":75,"extra_data":77,"updated_unix":79},105,"en","california-health-insurance-marketplace-statement-form-ftb-3895-instructions","California Health Insurance Marketplace Statement - Form FTB 3895 Instructions","","California Health Insurance Marketplace Statement provides guidance for reporting information to the Franchise Tax Board (FTB) for individuals enrolled in a qualified health plan through the California Health Insurance Marketplace. It explains how to handle corrected or void Forms FTB 3895, how related forms must be completed, and how to request corrections or disputes. The notice also includes general information on minimum essential coverage requirements, support resources, and steps to access a digital copy.",{"@graph":14,"@context":72},[15,34,55],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/letters/","Letters",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/california-health-insurance-marketplace-statement-form-ftb-3895-instructions/302200/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/california-health-insurance-marketplace-statement-form-ftb-3895-instructions/302200.png","ImageObject",442,249,{"name":42,"@type":43},"Jacob","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-09-27","2026-09-19",true,{"@type":52,"interactionType":53,"userInteractionCount":33},"InteractionCounter",{"@type":54},"ViewAction",{"@type":56,"mainEntity":57},"FAQPage",[58,64,68],{"name":59,"@type":60,"acceptedAnswer":61},"What should you do if the updated state tax Form FTB 3895 is marked “CORRECTED” or “VOID”?","Question",{"text":62,"@type":63},"If “CORRECTED” is checked, the information on the original Form FTB 3895 changed, and key details may have been updated. If “VOID” is checked, changes indicate you were never enrolled in the plan, and you must use the updated Form FTB 3895 information.","Answer",{"name":65,"@type":60,"acceptedAnswer":66},"Which form should you use to fill out Form FTB 3849?",{"text":67,"@type":63},"Use the information on the updated Form FTB 3895 to fill out Form FTB 3849, and do not use information from the earlier Form FTB 3895 for the same plan.",{"name":69,"@type":60,"acceptedAnswer":70},"Where can you request a correction or dispute if you think the form is still incorrect?",{"text":71,"@type":63},"Call Covered California at {SERVICE_CENTER_PHONE} (TTY:1-888-889-4500) or file an online dispute at CoveredCA.com/3895 by selecting “Errors on your forms?” and completing the Request to Correct or Dispute Tax Forms.","https://schema.org",{"og:url":32,"og:type":74,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":76,"canonical":32},"index,follow",{"doc_id":78,"site_id":7},302200,1790437396,{"code":4,"msg":81,"data":82},"success",[83,88,93,98,103,108,113,117,122],{"id":84,"doc_module":22,"doc_module_name":25,"category_name":85,"show_sort_weight":86,"slug":87},11,"Presentations",90,"presentations",{"id":89,"doc_module":22,"doc_module_name":25,"category_name":90,"show_sort_weight":91,"slug":92},12,"Resumes",80,"resumes",{"id":94,"doc_module":22,"doc_module_name":25,"category_name":95,"show_sort_weight":96,"slug":97},14,"Invoices",70,"invoices",{"id":99,"doc_module":22,"doc_module_name":25,"category_name":100,"show_sort_weight":101,"slug":102},15,"Posters",60,"posters",{"id":104,"doc_module":22,"doc_module_name":25,"category_name":105,"show_sort_weight":106,"slug":107},16,"Social 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Templates",5,"papers-templates",{"id":123,"doc_module":22,"doc_module_name":25,"category_name":124,"show_sort_weight":4,"slug":125},158,"General","general-158",{"code":4,"msg":81,"data":127},{"doc_id":78,"user_id":128,"nickname":42,"user_avatar":129,"doc_module":22,"category_id":114,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":33,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":135,"language":136,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":12,"update_tm":140,"read_time":30},962084931830,"https://ap-avatar.wpscdn.com/davatar_a8503ba1806abce46bf441b54a3ca4cd","{FIRST_NAME}{LAST_NAME}{ADDRESS_LINE1}{ADDRESS_LINE2}{CITY},{STATE_CD(FK)}{ZIPCODE}  \nWhat to do next  \n# Your updated state tax form for {Tax Year}\n\n{CURRENT_DATE}  \nDear {FIRST_NAME}{LAST_NAME},  \nYour updated state tax Form FTB 3895 is at the end of this letter  \nCovered California updated your state tax Form FTB 3895.This is because we got new informationabout your case.The last Form FTB 3895 you got for this plan is no longer correct.  \nIf the“CORRECTED”box is checked at the top of the form  \nThis means the information on your original Form FTB 3895 changed.Here are some things thatcould have changed:  \n·Your personal information,such as your address  \n·Your health plan information,such as enrolled members or health plan start and end dates  \n·Your premium(monthly cost)or California premium subsidy amount  \nIf the \"VOID\"box is checked at the top of the form  \nThis means changes were made to show that you were never enrolled in this plan.  \nUse the information on your updated Form FTB 3895 to fill out Form FTB 3849.Do not use theinformation on the last Form FTB 3895 you got for this plan.If you already filed your Californiaincome tax return for {Tax Year},you may need to file an amended (updated)state tax return.  \nImportant:You may also get an updated federal IRS Form 1095-A  \nYour destination for affordablehealthcare,including Medi-Cal  \nCase Number:{AHBX CASE ID}  \nIf you think we made a mistake  \nIf you think we made a mistake or your updated Form FTB 3895 is still incorrect,callCoveredCalifornia at {SERVICE_CENTER_PHONE}(TTY:1-888-889-4500).You can also file a Form FTB3895 dispute with Covered California online at CoveredCA.com/3895.Click “Errors on your forms?”Then fill out the Request to Correct or Dispute Tax Forms.  \nIf you need help with your taxes  \nCovered California may be able to answer questions but cannot give tax advice.For help with yourtaxes:  \n● Talk to a tax adviser  \n·Contact the IRS Volunteer Income Tax Assistance(VITA)or the Tax Counseling for theElderly(TCE)programs for free tax help.VITA helps people who make $58,000 or lessper year,persons with disabilities,and limited English-speaking taxpayers.TCE helpspeople 60 years of age or older.To find free help near you:  \no Go online to irs.treasury.gov/freetaxprep  \no Call 1-800-906-9887  \n● Visit the Franchise Tax Board's website at FTB.ca.gov.You can learn more about filingyour state tax return,the California premium subsidy,and the California IndividualShared Responsibility Penalty.  \nIf you need a digital copy  \nLog in to vour account at CoveredCA.com.On the homepage,click \"View{Tax Year}Califomia TaxForm 3895.”To create an online account.follow the instructions at CoveredCA.com/create-account.  \nQuestions?  \n● Go online to CoveredCA.com/3895  \n·Call Covered Califomia,Monday-Friday,8 a.m.to 6 p.m.at {SERVICE_CENTER_PHONE}  \n(TTY:1-888-889-4500).  \nThank you,  \nCovered California  \nThis notice was sent to you in compliance with Section 61005 of the Revenue and Taxation Code.  \n|  | CORRECTED  \u003Cbr>VOID   |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- |\n| Recpiants name   |  | Inital    | Last name   | Sfx   | Pacpiant SSN   | Pocipiorts dte ot birth   |\n| Spouse's irst name   |  | inital   |  Last name   | 5ux   | spousns SSN   | Spous0dm of birn   |\n\nAd055 ptSte,00m,PO box,C PM m)  \n\n| Cty   |  |  | Stan   | ZPcod9   |\n| --- | --- | --- | --- | --- |\n| Marslace idntng   | Manntplac9-assigned poicy umDB   | Poiky isSuer's name   |  |  |\n|  |  |  |  |  |\n| Poicy startdte   | Poicy trminaton dit9   | Repayment cap may not apply   |  |  |\n\n## PartI Covered Individuals\n\n\n| (a)  \u003Cbr>Covered individual name   |  | (b)  \u003Cbr>Covered  \u003Cbr>indimidual SSN   | (C)  \u003Cbr>Covered individual  \u003Cbr>date of birth   | (□)  \u003Cbr>Coverage  \u003Cbr>start date   | (e)  \u003Cbr>Cowerage  \u003Cbr>termination date   |\n| --- | --- | --- | --- | --- | --- |\n| FIrst name   | Last name   |  |  |  |  |\n|  |  |  |  |  |  |\n| 2   |  |  |  |  |  |\n| 3   |  |  |  |  |  |\n| 4   |  |  |  ","cbCairiGvwn4l0vc","https://ap.wps.com/l/cbCairiGvwn4l0vc","pdf",1104483,7,"English","# Your updated state tax form for {Tax Year}\n## Corrected and Void Forms FTB 3895\n## If you think we made a mistake\n## If you need help with your taxes\n## If you need a digital copy\n# 2021 Instructions for Form FTB 3895\n## General Information\n## Purpose\n## Minimum Essential Coverage Individual Mandate","[{\"question\":\"What should you do if the updated state tax Form FTB 3895 is marked “CORRECTED” or “VOID”?\",\"answer\":\"If “CORRECTED” is checked, the information on the original Form FTB 3895 changed, and key details may have been updated. If “VOID” is checked, changes indicate you were never enrolled in the plan, and you must use the updated Form FTB 3895 information.\"},{\"question\":\"Which form should you use to fill out Form FTB 3849?\",\"answer\":\"Use the information on the updated Form FTB 3895 to fill out Form FTB 3849, and do not use information from the earlier Form FTB 3895 for the same plan.\"},{\"question\":\"Where can you request a correction or dispute if you think the form is still incorrect?\",\"answer\":\"Call Covered California at {SERVICE_CENTER_PHONE} (TTY:1-888-889-4500) or file an online dispute at CoveredCA.com/3895 by selecting “Errors on your forms?” and completing the Request to Correct or Dispute Tax Forms.\"}]","California Health Insurance Marketplace Statement - Form FTB 3895 Instructions | PDF",1789790206]