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Form 3853-2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by entering your name as shown on your California tax return at the top of the form.
- In Part I, list all applicable household members. Include their last names, first names, initials, Social Security Numbers (SSNs), and dates of birth.
- For Part II, check the box if your applicable household income is below the filing threshold. This will exempt you from the Individual Shared Responsibility Penalty.
- In Part III, indicate any coverage exemptions claimed for each individual by entering the appropriate codes in columns (a) through (m).
- Finally, calculate any penalties in Part IV and enter the amount on your main tax forms as instructed.
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form 3853 health coverage exemption
Part I Applicable Household Members. List all members of your applicable household whether or not they have an exemption or an Exemption.Read more
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