Form 3853-2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your name as shown on your California tax return at the top of the form.
3. In Part I, list all applicable household members. Include their last names, first names, initials, Social Security Numbers (SSNs), and dates of birth.
4. 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.
5. In Part III, indicate any coverage exemptions claimed for each individual by entering the appropriate codes in columns (a) through (m).
6. Finally, calculate any penalties in Part IV and enter the amount on your main tax forms as instructed.

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