Form FTB 3853 (2025) — Health Coverage Exemptions and Individual Shared Responsibility Penalty

TAXABLE YEA TAXABLE YEAR 2
TAXABLE YEAR 2025 Health Coverage Exempti
R 2025 Health Coverage Exemptions and Individual Shared Responsibility Penalty CALIFORNIA FORM 3853 025 Health Coverage Exemptions and Individual Shared Responsibility Penalty CALIFORNIA FORM 3853 ons and Individual Shared Responsibility Penalty CALIFORNIA FORM 3853 Attach to your California Form 540, Form 540NR, or Form 540 2EZ.
Name(s) as shown on your California tax return SSN or ITIN
Part I Applicable Household Members. List all members of your applicable household whether or not they have an exemption or an Exemption

Text version of this table

1	First Name	Initial	SSN	Date of Birth (mm/dd/yyyy)	Modified AGI
	Last Name		ECN 1	ECN 2	ECN 3
2	First Name	Initial	SSN	Date of Birth (mm/dd/yyyy)	Modified AGI
	Last Name		ECN 1	ECN 2	ECN 3
3	First Name	Initial	SSN	Date of Birth (mm/dd/yyyy)	Modified AGI
	Last Name		ECN 1	ECN 2	ECN 3
4	First Name	Initial	SSN	Date of Birth (mm/dd/yyyy)	Modified AGI
	Last Name		ECN 1	ECN 2	ECN 3
5	First Name	Initial	SSN	Date of Birth (mm/dd/yyyy)	Modified AGI
	Last Name		ECN 1	ECN 2	ECN 3
6	First Name	Initial	SSN	Date of Birth (mm/dd/yyyy)	Modified AGI
	Last Name		ECN 1	ECN 2	ECN 3
7	First Name	Initial	SSN	Date of Birth (mm/dd/yyyy)	Modified AGI
	Last Name		ECN 1	ECN 2	ECN 3
8	First Name	Initial	SSN	Date of Birth (mm/dd/yyyy)	Modified AGI
	Last Name		ECN 1	ECN 2	ECN 3
9	First Name	Initial	SSN	Date of Birth (mm/dd/yyyy)	Modified AGI
	Last Name		ECN 1	ECN 2	ECN 3
10	First Name	Initial	SSN	Date of Birth (mm/dd/yyyy)	Modified AGI
	Last Name		ECN 1	ECN 2	ECN 3
11	First Name	Initial	SSN	Date of Birth (mm/dd/yyyy)	Modified AGI
	Last Name		ECN 1	ECN 2	ECN 3
12	First Name	Initial	SSN	Date of Birth (mm/dd/yyyy)	Modified AGI
	Last Name		ECN 1	ECN 2	ECN 3

# Part II Coverage Exemption Claimed on Your Tax Return for Your Household

1 If you are claiming a coverage exemption because your applicable household income or gross income is below the filing threshold, check the box here. See instructions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • FTB 3853 2025 Side 1
For Privacy Notice, get FTB 1131 EN-SP.

Part III Coverage and Exemptions Claimed on Your Tax Return for Individuals. If you and/or a member of your applicable household are reporting any coverage or are claiming exemptions for the tax year, complete Part III. See instructions.
Coverage and Exemption Codes
(a) (b) (c) (d) (e) (f)
Full-year Jan Feb Mar Apr May First Name Initial Last Name First Name Initial Last Name First Name Initial Last Name First Name Initial Last Name First Name Initial Last Name First Name Initial Last Name First Name Initial Last Name First Name Initial Last Name First Name Initial Last Name First Name Initial Last Name First Name Initial Last Name First Name Initial Last Name

# Part IV Individual Shared Responsibility Penalty

(g) (h) (i) (j) (k) (l) (m)
June July Aug Sept Oct Nov Dec Your Individual Shared Responsibility Penalty. Enter on Form 540, line 92; Form 540NR, line 91; or Form 540 2EZ, line 27.
See instructions … • 1
Side 2 FTB 3853 2025