DEPARTMENT OF HEALTH AND HUMAN SERVICES

465 INDUSTRIAL BOULEVARD

LONDON, KENTUCKY 40750-0001

MUMTAZ MAKDA January 5, 2022

1000 Buckshot Ct
Murphy, TX 75094-3616

Application ID: 3678975708

Plan Name: Constant Care Silver 1 100

You must file a tax return if the enclosed Form 1095-A shows that you got advance payments of the premium tax
credit. See Part III, Column C on your form.

Use Form 1095-A to complete “IRS Form 8962, Premium Tax Credit” with your federal income tax return when you
file. If you don’t complete this step, you may have to pay back some or all of the advance premium tax credits you
used last year.

Dear MUMTAZ MAKDA:

Because you and/or members of your household had Health Insurance Marketplace® coverage for all or some part of
2021, we're required to provide you with the enclosed IRS Form 1095-A from the Marketplace. The form includes
important information you'll need to correctly fill out your federal income tax return for that year. This information also
has been given to the Internal Revenue Service (IRS). After using this information for tax filing, please keep this form for
your records.

You must file a tax return

You must file a federal income tax return if you or another member of your household received any advance payments
of the premium tax credit in 2021 to lower premium costs, even if you don't normally file a return. If advance payments
are made on behalf of you or an individual in your family and you don't file a tax return:
• You may have to pay back all or some of the advance payments of the premium tax credits you used.
• You won't be eligible for advance payments of the premium tax credit or cost-sharing reductions to help pay for
your Marketplace health coverage in future years.

When you file your tax return electronically or by mail, you must complete and file "Form 8962, Premium Tax Credit."
Use the information on the included Form 1095-A to complete Form 8962. The Form 1095-A also indicates which
months of 2021 you and other members of your household had health coverage. You'll need that information to
complete your tax return. More information about Form 1095-A can be found in the "Instructions for Recipient" section
on the back of the enclosed form. If you need Form 8962, visit IRS.gov/aca.

3678975708 1
Many people who signed up for Marketplace coverage can get free assistance with filling out their taxes. This may
include free access to tax software programs, or free in-person assistance. For more information, visit IRS.gov/freefile or
IRS.gov/VITA.

Why Form 1095-A is important

Form 1095-A includes:
• Information about you and any other members of your household who were enrolled in a Marketplace plan
during 2021.
• Information about your Marketplace plan premium and other information you may need to fill out your federal
income tax return and claim the Premium Tax Credit.
• The amount of any advance payments of the premium tax credit that we paid in 2021 to a health plan on your
behalf or on behalf of other members of your household.
To learn more about using your form, visit HealthCare.gov/tax-form-1095.

You may need more information to complete your tax return

Visit HealthCare.gov/tax-tool to get the additional information you need to figure out your premium tax credit if:
• You had changes in your household that you didn't report to the Marketplace - like having a baby, moving,
getting married or divorced, or losing a dependent.
• Your Form 1095-A has zeroes printed in Part III, column B for the months you had coverage.
You can also visit IRS.gov to find more details in the Instructions for Form 8962.

Changes to your Form 1095-A information

If you think information on the attached Form 1095-A is incorrect, call the Marketplace Call Center at 1-800-318-2596 to
find out how to get a corrected Form 1095-A. TTY users should call 1-855-889-4325.

It's important to note that you may receive more than one Form 1095-A. This may happen if different members of your
household had different health plans, you updated your coverage information during 2021, or you switched plans during
2021. Be sure to keep all Forms 1095-A with your important tax documents.

You also may get Form 1095-B or Form 1095-C

If you or members of your household had coverage in 2021 through other programs or plans outside of the Marketplace,
you may also get a "Form 1095-B, Health Coverage" or "Form 1095-C, Employer-Provided Health Insurance Offer and
Coverage." It's important to follow the instructions on these forms, so you fill out your federal income tax return
correctly.

NOTE: If you're enrolled in another type of health coverage that qualifies as minimum essential coverage (for example,
Medicare Part A) and received a Form 1095-B, you may no longer be eligible to receive financial assistance for your
Marketplace plan. It's important to contact the Marketplace and report any changes in your coverage as soon as
possible.

For more information, visit HealthCare.gov/taxes/other-health-coverage.

How to get help with your taxes

Many people can get free help to fill out their taxes. Visit
IRS.gov/Individuals/Free-Tax-Return-Preparation-for-You-by-Volunteers to learn more about getting help.

Using tax preparation software is the best and simplest way to file a complete and accurate tax return, as it guides
individuals and tax preparers through the process and does all the math. Electronic filing options include IRS Free File for
taxpayers who qualify, free volunteer assistance, commercial software, and professional assistance.

3678975708 2
If you need more information, visit HealthCare.gov/taxes or call the Marketplace Call Center.

For more help

• Visit IRS.gov if you have general questions about your taxes. Free tax help is available if you qualify through Free
File or Volunteer Income Tax Assistance.
• Visit HealthCare.gov, or call the Marketplace Call Center at 1-800-318-2596 for questions about the
Marketplace. TTY users can call 1-855-889-4325. You can also make an appointment with a local assister who
can help you. Information is available at LocalHelp.HealthCare.gov.
• Get help in a language other than English. Information is included with this notice and available through the
Marketplace Call Center.
• Call the Marketplace Call Center to get this information in an accessible format, like large print, Braille, or audio,
at no cost to you.

Sincerely,

Health Insurance Marketplace

Department of Health and Human Services
465 Industrial Boulevard
London, Kentucky 40750-0001

Privacy Disclosure: The Health Insurance Marketplace® protects the privacy and security of the personally identifiable information (PII) that you
have provided (see HealthCare.gov/privacy/). This notice was generated by the Marketplace based on 45 CFR 155.230 and 45 CFR part 155, subpart
D. The PII used to create this notice was collected from information you provided to the Health Insurance Marketplace®. The Marketplace may
have used data from other federal or state agencies or a consumer reporting agency to determine eligibility for the individuals on your application.
If you have questions about this data, contact the Marketplace at 1-800-318-2596 (TTY: 1-855-889-4325).

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB
control number. The valid OMB control number for this information collection is 0938-1207.

Nondiscrimination: The Health Insurance Marketplace® doesn't exclude, deny benefits to, or otherwise discriminate against any person on the basis
of race, color, national origin, disability, sex, or age. If you think you've been discriminated against or treated unfairly for any of these reasons, you
can file a complaint with the Department of Health and Human Services, Office for Civil Rights by calling 1-800-368-1019 (TTY: 1-800-537-7697),
visiting hhs.gov/ocr/civilrights/complaints, or writing to the Office for Civil Rights/ U.S. Department of Health and Human Services/200
Independence Avenue, SW/ Room 509F, HHH Building/ Washington, D.C. 20201.

Health Insurance Marketplace® is a registered service mark of the U.S. Department of Health & Human Services.

3678975708 3
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3678975708 4
Form 1095-A Health Insurance Marketplace Statement VOID OMB No. 1545-2232

Department of the Treasury

Internal Revenue Service ▶
▶ Do not attach to your tax return. Keep for your records.

Go to www.irs.gov/Form1095A for instructions and the latest information.

CORRECTED 2021
Part I Recipient Information
1 Marketplace identifier 2 Marketplace-assigned policy number 3 Policy issuer's name
TX 91859121 Molina Healthcare
4 Recipient's name 5 Recipient's SSN 6 Recipient's date of birth
MUMTAZ MAKDA xxx-xx-0041
7 Recipient's spouse's name 8 Recipient's spouse's SSN 9 Recipient's spouse's date of birth
NABILA M MAKDA xxx-xx-7211
10 Policy start date 11 Policy termination date 12 Street address (including apartment no.)
01/01/2021 12/31/2021 1000 Buckshot Ct
13 City or town 14 State or province 15 Country and ZIP or foreign postal code
Murphy TX US 75094-3616
Part II Covered Individuals

A. Covered individual name B. Covered individual SSN C. Covered individual D. Coverage start date E. Coverage termination date
date of birth

16 MUMTAZ MAKDA xxx-xx-0041 01/01/2021 12/31/2021

17 NABILA M MAKDA xxx-xx-7211 01/01/2021 12/31/2021

18 HIJAB M MAKDA xxx-xx-3764 01/01/2021 12/31/2021

19

20

Part III Coverage Information

Month A. Monthly enrollment premiums B. Monthly second lowest cost silver C. Monthly advance payment of
plan (SLCSP) premium premium tax credit

21 January 1,819.62 2,150.19 1,778.90

22 February 1,819.62 2,150.19 1,778.90

23 March 1,819.62 2,150.19 1,778.90

24 April 1,819.62 2,150.19 1,778.90

25 May 1,819.62 2,150.19 1,778.90

26 June 1,819.62 2,150.19 1,778.90

27 July 1,819.62 2,150.19 1,778.90

28 August 1,819.62 2,150.19 1,778.90

29 September 1,819.62 2,156.83 1,819.62

30 October 1,819.62 2,156.83 1,819.62

31 November 1,819.62 2,156.83 1,819.62

32 December 1,819.62 2,156.83 1,819.62

33 Annual Totals 21,835.44 25,828.84 21,509.68

For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. Cat. No. 60703Q Form 1095-A (2021)
Form 1095-A (2021)

Instructions for Recipient If advance credit payments are made, the only individuals listed on
Form 1095-A will be those whom you certified to the Marketplace would
You received this Form 1095-A because you or a family member be in your tax family for the year of coverage (yourself, spouse, and
enrolled in health insurance coverage through the Health Insurance dependents). If you certified to the Marketplace at enrollment that one or
Marketplace. This Form 1095-A provides information you need to more of the individuals who enrolled in the plan aren’t individuals who
complete Form 8962, Premium Tax Credit (PTC). You must complete would be in your tax family for the year of coverage, those individuals
Form 8962 and file it with your tax return (Form 1040, Form won’t be listed on your Form 1095-A. For example, if you indicated to
1040-SR, or Form 1040-NR) if any amount other than zero is shown the Marketplace at enrollment that an individual enrolling in the policy is
in Part III, column C, of this Form 1095-A (meaning that you your adult child who will not be your dependent for the year of coverage,
received premium assistance through advance payments of the that child will receive a separate Form 1095-A and won’t be listed in
premium tax credit (also called advance credit payments)) or if you Part II on your Form 1095-A.
want to take the premium tax credit. The filing requirement applies If advance credit payments are made and you certify that one or more
whether or not you’re otherwise required to file a tax return. If you are enrolled individuals aren’t individuals who would be in your tax family for
filing Form 8962, you cannot file Form 1040-NR-EZ, Form the year of coverage, your Form 1095-A will include coverage
1040-SS, or Form 1040-PR. The Marketplace has also reported the information in Part III that is applicable solely to the individuals listed on
information on this form to the IRS. If you or your family members your Form 1095-A, and separately issued Forms 1095-A will include
enrolled at the Marketplace in more than one qualified health plan coverage information, including dollar amounts, applicable to those
policy, you will receive a Form 1095-A for each policy. Check the individuals not in your tax family.
information on this form carefully. Please contact your Marketplace if
If advance credit payments weren’t made and you didn’t identify at
you have questions concerning its accuracy. If you or your family
enrollment the individuals who would be in your tax family for the year of
members were enrolled in a Marketplace catastrophic health plan or
coverage, Form 1095-A will list all enrolled individuals in Part II on your
separate dental policy, you aren’t entitled to take a premium tax credit
Form 1095-A.
for this coverage when you file your return, even if you received a Form
1095-A for this coverage. For additional information related to Form If there are more than 5 individuals covered by a policy, you will
1095-A, go to www.irs.gov/Affordable-Care-Act/Individuals-and- receive one or more additional Forms 1095-A that continue Part II.
Families/Health-Insurance-Marketplace-Statements. Part III. Coverage Information, lines 21–33. Part III reports information
Additional information. For additional information about the tax about your insurance coverage that you will need to complete Form
provisions of the Affordable Care Act (ACA), including the premium tax 8962 to reconcile advance credit payments or to take the premium tax
credit, see www.irs.gov/Affordable-Care-Act/Individuals-and-Families or credit when you file your return.
call the IRS Healthcare Hotline for ACA questions (800-919-0452). Column A. This column is the monthly premiums for the plan in which
VOID box. If the “VOID” box is checked at the top of the form, you you or family members were enrolled, including premiums that you paid
previously received a Form 1095-A for the policy described in Part I. and premiums that were paid through advance payments of the
That Form 1095-A was sent in error. You shouldn’t have received a premium tax credit. If you or a family member enrolled in a separate
Form 1095-A for this policy. Don’t use the information on this or the dental plan with pediatric benefits, this column includes the portion of
previously received Form 1095-A to figure your premium tax credit on the dental plan premiums for the pediatric benefits. If your plan covered
Form 8962. benefits that aren’t essential health benefits, such as adult dental or
vision benefits, the amount in this column will be reduced by the
CORRECTED box. If the “CORRECTED” box is checked at the top of
premiums for the non-essential benefits. If the policy was terminated by
the form, use the information on this Form 1095-A to figure the premium
your insurance company due to nonpayment of premiums for 1 or more
tax credit and reconcile any advance credit payments on Form 8962.
months, then a -0- will appear in this column for these months
Don’t use the information on the original Form 1095-A you received for
regardless of whether advance credit payments were made for these
this policy.
months.
Part I. Recipient Information, lines 1–15. Part I reports information
Column B. This column is the monthly premium for the second lowest
about you, the insurance company that issued your policy, and the
cost silver plan (SLCSP) that the Marketplace has determined applies to
Marketplace where you enrolled in the coverage.
members of your family enrolled in the coverage. The applicable SLCSP
Line 1. This line identifies the state where you enrolled in coverage premium is used to compute your monthly advance credit payments
through the Marketplace. and the premium tax credit you take on your return. See the instructions
Line 2. This line is the policy number assigned by the Marketplace to for Form 8962, Part II, on how to use the information in this column or
identify the policy in which you enrolled. If you are completing Part IV of how to complete Form 8962 if there is no information entered. If the
Form 8962, enter this number on line 30, 31, 32, or 33, box a. policy was terminated by your insurance company due to nonpayment
of premiums for 1 or more months, then a -0- will appear in this column
Line 3. This is the name of the insurance company that issued your
for the months, regardless of whether advance credit payments were
policy.
made for these months.
Line 4. You are the recipient because you are the person the
Column C. This column is the monthly amount of advance credit
Marketplace identified at enrollment who is expected to file a tax return
payments that were made to your insurance company on your behalf to
and who, if qualified, would take the premium tax credit for the year of
pay for all or part of the premiums for your coverage. If this is the only
coverage.
column in Part III that is filled in with an amount other than zero for a
Line 5. This is your social security number (SSN). For your protection, month, it means your policy was terminated by your insurance company
this form may show only the last four digits. However, the Marketplace due to nonpayment of premiums, and you aren’t entitled to take the
has reported your complete SSN to the IRS. premium tax credit for that month when you file your tax return. You
Line 6. A date of birth will be entered if there is no SSN on line 5. must still reconcile the entire advance payment that was paid on your
behalf for that month using Form 8962. No information will be entered in
Lines 7, 8, and 9. Information about your spouse will be entered only if
this column if no advance credit payments were made.
advance credit payments were made for your coverage. The date of
birth will be entered on line 9 only if line 8 is blank. Lines 21–33. The Marketplace will report the amounts in columns A, B,
and C on lines 21–32 for each month and enter the totals on line 33. Use
Lines 10 and 11. These are the starting and ending dates of the policy.
this information to complete Form 8962, line 11 or lines 12–23.
Lines 12 through 15. Your address is entered on these lines.
Part II. Covered Individuals, lines 16–20. Part II reports information
about each individual who is covered under your policy. This information
includes the name, social security number, date of birth, and the starting
and ending dates of coverage for each covered individual. For each line,
a date of birth is reported in column C only if an SSN isn’t entered in
column B.

3678975708 6
January 2019
January 2019