ACA EXPLANATION FORM

ACA Explanation Letter

Explanation of No Marketplace Coverage
Taxpayer Full Name*

First NameLast Name
To Whom It May Concern,

I am writing to formally respond to the request for Form 8962/1095-A. I, did not purchase health insurance through the Marketplace (Healthcare.gov, ObamaCare or state equivalent) at any time during the 2025 tax year.

No member of my tax household was enrolled in a qualified health plan through the Marketplace. Therefore, I did not receive a Form 1095-A, and I am not required to file Form 8962.

Please process this return based on this statement.
MedicaidMedicareEmployer Provided CoverageOther
MedicaidMedicareEmployer Provided CoverageOther
Signature*
Date*

MonthDayYear
Date
Taxpayer SSN Date of Birth*

SSNDOB
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