HARDSHIP Application for Exemption from the Shared Responsibility Payment for Individuals who Experience Hardships

You may qualify for a hardship exemption if you experienced one of the following:
Submit this documentation with your application
1 You were homeless.
None

2 You were evicted in the past 6 months or were facing eviction or foreclosure.
Copy of eviction or foreclosure notice

3 You received a shut-off notice from a utility - Copy of shut-off notice from a utility company
company.

4 You recently experienced domestic violence.
None

5 You recently experienced the death of a close family member.
Copy of death certificate, copy of death notice from newspaper, or copy of other official notice of death

6 You experienced a fire, flood, or other natural human-caused disaster that caused substantial damage to your property.
Copy of police or fire report, insurance claim, or other document from government agency, private entity, or news source documenting event

7 You filed for bankruptcy in the last 6 months.
Copy of bankruptcy filing

8 You had medical expenses you couldn’t pay in the last 24 months.
Copies of medical bills

9 You experienced unexpected increases in necessary expenses due to caring for an ill, disabled, or aging family member.
Copies of receipts related to care

10 You expect to claim a child as a tax dependent who’s been denied coverage in Medicaid and the Children’s Health Insurance Program (CHIP), and another person is required by court order to give medical support to the child.
Copy of medical support order AND copies of eligibility notices for Medicaid and CHIP showing that the child has been denied coverage

11 As a result of an eligibility appeals decision, you’re eligible either for: 1) enrollment in a qualified health plan (QHP) through the Marketplace, 2)lower costs on your monthly premiums, or3)cost-sharing reductions for a time period whenyou weren’t enrolled in a QHP through the Marketplace.
Copy of notice of appeals decision

12 You were determined ineligible for Medicaid because your state didn’t expand eligibility for Medicaid under the Affordable Care Act.
Copy of notice of denial of eligibility for Medicaid

13 You received a notice saying that your current health insurance plan is being cancelled, and you consider the other plans available unaffordable.
Copy of notice of cancellation