3853 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.

File form FTB 3853 to report or claim a coverage exemption and/or calculate an Individual Shared Responsibility Penalty if all of the following apply. You are unable to check the full-year health care coverage box on Form 540, Form 540NR, or Form 540 2EZ.

Use Form FTB 3853 to determine if you owe an individual shared responsibility penalty or to claim exemptions from the state individual health coverage mandate on your California state tax return.

Overview of the Form 3853 menu in TaxSlayer Pro Part I - Marketplace-Granted Coverage Exemptions - If anyone in the household has an ECN from Covered California, enter it here and indicate the months covered by that exemption.

Residents of California must provide documentation by completing Form FTB 3853, a tax form that must be enclosed with your Form 540, California Resident Income Tax Return. Below, you will find detailed instructions and a sample of completed Sides 1 and 3 of Form 540 and a sample of Side 1 and Side 2 of Form FTB 3853.

Residents of California must provide this documentation by completing Form FTB 3853, a tax form that must be enclosed with your Form 540, California Resident Income Tax Return. Below, you will find detailed instructions and a sample of completed Sides 1 and 3 of Form 540 and a sample of Side 1 and Side 2 of Form FTB 3853.

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 …

Use the exemption certificate number (ECN) provided by Covered California in the exemption approval notice when you complete your state taxes. This number is needed on Form FTB 3853, Health Coverage Exemptions and Individual Shared Responsibility Penalty, to prove that Covered California granted you an exemption from the penalty.

File form FTB 3853 to report or claim a coverage exemption and/ or calculate an Individual Shared Responsibility Penalty if all of the following apply.