Application for Exemption for American Indians and Alaska Natives

Date: March 27, 2014 Author: ITCNCCDF Categories: Events, ITCN CCDF, News, Our Program, Parents, Providers


Application for Exemption for American Indians and Alaska Natives and Other Individuals who are Eligible to Receive Services from an Indian Health Care Provider


Click Here: Tribal Exemption Form

Use this application to apply for an exemption from the shared responsibility payment

• Starting in 2014, 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 includes 2 categories of exemptions. There are other applications for other categories of exemptions. You may apply for certain other categories of exemptions when you file your federal income tax return. If you’re a member of an Indian tribe, you can ask the Internal Revenue Service (IRS) for this exemption when you file your federal income tax return.
• You don’t need to ask for an exemption if you’re not going to file a federal income tax return because your income is below the filing threshold. If you’re not sure, you may want to ask for an exemption.

Who can use this application?

• Use this application if you and/or anyone in your tax household is:
• A member of an Indian tribe.
• Another individual who’s eligible for health services through the Indian Health Service, tribes and tribal organizations,or urban Indian organizations.
• If you get this exemption, you can keep it for future years without submitting another application if your membership or eligibility for services from an Indian health care provider remains unchanged.
• You can use one application to apply for this exemption for more than one person in your tax household.

What you need to apply

• Documents showing tribal membership or eligibility for services from the Indian Health Service, a tribal health care provider, or an urban Indian health care provider (see page 4).
• 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 or see instructions.

What happens next?
Send your complete, signed application with documents to the address on page 3. We’ll follow-up with you within 1–2 weeks and let you know if we need additional information. If you get this exemption, we’ll give you an Exemption Certificate Number that you’ll put on your federal income tax return. If you don’t hear from us, visit, or call the Health Insurance Marketplace Help Center at 1-800-318-2596. TTY users should call 1-855-889-4325.

Get help with this application

• Online:
• Phone: Call our Health Insurance Marketplace Call Center at 1-800-318-2596.
• In person: There may be counselors in your area who can help. Visit or call 1-800-318-2596 for more information.
• En Español: Llame a nuestro centro de ayuda gratis al NEED HELP WITH YOUR APPLICATION? Visit 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.

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