NJ Health Insurance Mandate
Please provide some basic information about the whole NJ Tax Family. Include all people even if you are only seeking an Exemption for some people. Note: include dependents who could have been claimed as well as those who were actually claimed.
Filing Status: * Dependents:
Note: You are exempt from the NJ Health Insurance Mandate if your NJ-1040, line 29 is less than
Check if you can be claimed as a dependent on someone else's return
STOP! If you can be claimed as a dependent on someone else's return - stop now.
You do not need to provide Insurance information on your return. (Insurance issues will be dealt with on the return of whoever can claim you as a dependent.)
Family Size: Federal Poverty Level (FPL): 12,345
First we'll determine if you are eligible for the Poverty Exemption. You must include income for dependents here even if a dependent was not required to file a NJ return. If you do not have information from a dependent's return, you should estimate their income.
Tax Household Total NJ Income: • 138% of FPL: • NJ Percent of FPL: %
STOP! You qualify for the Poverty Exemption You do NOT qualify for the Poverty Exemption
This is a replica of the form NJ will ask you to fill in to apply for the Poverty Line Exemption
|Number of Household Family Members:|
|Qualification Status:||Qualified Not Qualified|
To calculate the applicable subsidy, we need information from your federal return. Include information from dependent's returns also. (You only need to include information for a dependent if they were required to file a return.)
Tax Household Total US Income:
To calculate the applicable subsidy, we need to calculate the applicable LCBP (and SLCSP) amounts. For this we need birthdays for everyone in the NJ Tax Family.
LCBP Base Monthly Rate: • SLCSP Base Monthly Rate:
Total Monthly LCBP: • Total Annual LCBP:
Total Monthly SLCSP: • Total Annual SLCSP:
Health Insurance offered by employer(s)
Form 8962 is used to calculate the PTC (subsidy) applicable for your situation. (It only shows up if Show Detail is checked.)
If filing status is MfS, then PTC is not allowed unless an exception applies.
(see Form 8962 Instructions for details.)
Check if MFS exception applies
|1||Tax family size|
|4||Federal poverty line|
|5||Household income as a percentage of federal poverty line||%|
|6||Is Household income outside PTC range (100% - 400%)|
|8a||Annual contribution amount|
|8b||Monthly contribution amount|
|24||Total premium tax credit|
Total premium tax credit (Monthly): • LCBP (subsidized) (Monthly):
This is a replica of the form NJ will ask you to fill in to apply for the Marketplace Affordability Exemption
|02||8.05% of NJ Household Income|
|03||Lowest Monthly Cost Bronze-Level plan (subsidized)|
|05||Qualify? (Is Line 04 > Line 02)||Qualified Not Qualified|
If you want to apply for a Job-Based Affordability Exemption, your Job-based insurance will need to cost more than 8.05% of your household income ( per month).
Click Here to apply for NJ Health Insurance Mandate Coverage Exemptions.
Please print a copy of this page for the TP to keep with their records.
You must still go to the NJ Health Insurance Mandate Exemption application page to officially apply for your exemption. You will receive an Exemption Number which you can then use on Schedule NJ-HCC.