Information regarding these forms has been reproduced below:

• Lulu was not eligible for health care benefits due to the part-time nature of her job, thus health insurance for the Clifden household was purchased by Gregory.
• The Clifdens are not eligible for an exemption from coverage. The Clifdens purchased health insurance through the Covered California program and received the Form 1095-A. They had no other health insurance during 2019.
• Assume that the self-employed health insurance deduction is $1,424.
• The Clifdens did not claim an advance premium credit.
• Click here to access the completed Form 1095-A to use when completing Form 8962.

Table for Federal Poverty Line

Persons in Family/Household	2019 FPL for 48 States and DC
1	$12,140
2	16,460
3	20,780
4	25,100
5	29,420
6	33,740
7	38,060
8	42,380
Each additional person	+ 4,320
The household income is then expressed as a percentage of the FPL.

Table for Repayment of the Credit Amount

	Single	Taxpayers Other Than Single
Less than 200%	$300	$600
At least 200% but less than 300%	800	1,600
At least 300% but less than 400%	1,325	2,650
At least 400%	No limit	No limit

Complete Tax Form 8962 and 8995