Form FTB 3853 (2024) — Health Coverage Exemptions and Individual Shared Responsibility Penalty

8661243 FTB 3853 2024 Side 1For Privacy Notice, get FTB 1131 EN-SP.
Health Coverage Exemptions and Individual
Shared Responsibility Penalty
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
Certificate Number (ECN) granted by the Marketplace. See instructions.
First Name Initial SSN Date of Birth (mm/dd/yyyy) Modified AGI
Last Name ECN 1 ECN 2 ECN 3
First Name Initial SSN Date of Birth (mm/dd/yyyy) Modified AGI
Last Name ECN 1 ECN 2 ECN 3
First Name Initial SSN Date of Birth (mm/dd/yyyy) Modified AGI
Last Name ECN 1 ECN 2 ECN 3
First Name Initial SSN Date of Birth (mm/dd/yyyy) Modified AGI
Last Name ECN 1 ECN 2 ECN 3
First Name Initial SSN Date of Birth (mm/dd/yyyy) Modified AGI
Last Name ECN 1 ECN 2 ECN 3
First Name Initial SSN Date of Birth (mm/dd/yyyy) Modified AGI
Last Name ECN 1 ECN 2 ECN 3
First Name Initial SSN Date of Birth (mm/dd/yyyy) Modified AGI
Last Name ECN 1 ECN 2 ECN 3
First Name Initial SSN Date of Birth (mm/dd/yyyy) Modified AGI
Last Name ECN 1 ECN 2 ECN 3
First Name Initial SSN Date of Birth (mm/dd/yyyy) Modified AGI
Last Name ECN 1 ECN 2 ECN 3
First Name Initial SSN Date of Birth (mm/dd/yyyy) Modified AGI
Last Name ECN 1 ECN 2 ECN 3
First Name Initial SSN Date of Birth (mm/dd/yyyy) Modified AGI
Last Name ECN 1 ECN 2 ECN 3
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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . •

# TAXABLE YEAR CALIFORNIA FORM

Attach to your California Form 540, Form 540NR, or Form 540 2EZ.

8662243Side 2 FTB 3853 2024

# Part IV Individual Shared Responsibility Penalty

1 Your Individual Shared Responsibility Penalty. Enter on Form 540, line 92; Form 540NR, line 91; or Form 540 2EZ, line 27.
See instructions • 1
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)
Full-year
(b)
Jan
(c)
Feb
(d)
Mar
(e)
Apr
(f)
May
(g)
June
(h)
July
(i)
Aug
(j)
Sept
(k)
Oct
(l)
Nov
(m)
Dec
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