DEPARTMENT OF HEALTH AND HUMAN SERVICES 465 INDUSTRIAL BOULEVARD LONDON, KENTUCKY 40750-000129279466651February 25, 2020Cecil Myers1321 Forest Park TerApt JStatesville, NC 28677Application ID: 2927946665 Plan Name: Blue Value 100 You must file a tax return if the enclosed Form 1095-A shows that you got advance payments of the premium tax credit. See Part III, Column C on your form. Dear Cecil Myers:A corrected"Form 1095-A, Health Insurance Marketplace Statement" is enclosed for coverage year 2019. You'll need information from this form when you file your 2019 federal income tax return.This corrected Form 1095-A replaces your original Form 1095-A. The correction may be the result of an error that you or your health insurance company reported on your original Form 1095-A. Disregard all earlier versions of Form 1095-A for Marketplace-assigned policy number 68827995 (see Box 2 of this form). This notice doesn'tapply to a Form 1095-A with a different Marketplace-assigned policy number, if you have one.You may get more than one Form 1095-AThis notice applies only to Form 1095-A for Marketplace-assigned policy number 68827995. You may get more than one Form 1095-A if different members of your household had different health plans, you updated your application information during 2019, or you switched plans during 2019. Be sure to keep all Forms 1095-A with your important tax documents.You must file a tax returnYou must file a federal income tax return if you or another member of your household got advance payments of the premium tax credit in 2019 to lower premium costs, even if you don't normally file a return. If advance payments are made on your or a family member's behalf and you don't file a tax return, you won't be eligible for advance payments of the premium tax credit or cost-sharing reductions to help pay for your Marketplace health coverage in future years.When you file your tax return electronically or by mail, you must complete and file "Form 8962, Premium Tax Credit." Use the information on this corrected Form 1095-A to complete Form 8962.The Form 1095-A also indicates which months of 2019 you and other members of your household had health coverage. You'll need that information to complete your tax return. More information about Form 1095-A can be found in the "Instructions for Recipient" section on the back of the enclosed form. If you need Form 8962, visit IRS.gov/aca.
29279466652Changes to your Form 1095-A informationIf you think information on the attached corrected Form 1095-A is incorrect, call the Marketplace Call Center at 1-800-318-2596 to find out how to get a new corrected Form 1095-A. TTY users can call 1-855-889-4325.Why Form 1095-A is importantForm 1095-A includes:• Information about any members of your household who were enrolled in a Marketplace plan during 2019.• Information about your Marketplace plan premium and other information you may need to fill out your federal income tax return.