3853: Health Coverage Exemption and Individual Shared Responsibility Penalty (2024)
California · FTB · Used for tax years 2024
California Form 3853 reports health coverage, coverage exemptions, and the Individual Shared Responsibility Penalty for 2024. It lists applicable household members and is attached to California Form 540, Form 540NR, or Form 540 2EZ.
Who files this form
California Form 3853 is used to report health coverage exemptions and the Individual Shared Responsibility Penalty for tax year 2024. Attach it to your California Form 540, Form 540NR, or Form 540 2EZ.
If you or a member of your applicable household are reporting coverage or claiming exemptions for the tax year, complete Part III. Part II is for claiming a household coverage exemption because applicable household income or gross income is below the filing threshold. The form does not state the threshold amount.
What you'll need
Have the following information ready to complete the form:
- Your name or names as shown on your California tax return, and your SSN or ITIN.
- Each applicable household member's name, SSN, date of birth, and modified adjusted gross income (AGI).
- Any Exemption Certificate Numbers (ECNs) granted by the Marketplace.
- Coverage and exemption codes for each person, for the full year or individual months, as applicable.
The form does not list supporting documents to submit.
How to file
Attach Form 3853 to your California Form 540, Form 540NR, or Form 540 2EZ.
Enter the Individual Shared Responsibility Penalty from Part IV, line 1, on the applicable return line:
- Form 540, line 92.
- Form 540NR, line 91.
- Form 540 2EZ, line 27.
The supplied form does not provide a mailing address or e-filing directions.
Common mistakes
- Leaving out household members: Part I says to list all members of your applicable household, whether or not they have an exemption or a Marketplace-issued ECN.
- Skipping Part III when it applies: Complete Part III if you or a household member are reporting coverage or claiming exemptions for the tax year.
- Not attaching the form: Form 3853 must be attached to your California Form 540, Form 540NR, or Form 540 2EZ.
- Not transferring the penalty: Enter the Part IV penalty on the return line specified for your California tax form.
Questions people ask
Do I list household members who do not have an exemption?
Yes. Part I says to list all members of your applicable household, whether or not they have an exemption or an Exemption Certificate Number granted by the Marketplace.
Where do I claim an exemption based on income below the filing threshold?
Check the box in Part II, line 1, if you are claiming a coverage exemption because your applicable household income or gross income is below the filing threshold. The form does not give the threshold amount.
Can I report coverage or exemptions by month?
Yes. Part III has a full-year column and separate columns for January through December for coverage and exemption codes.
Where does the penalty go on my California tax return?
Enter the penalty from Part IV, line 1, on Form 540, line 92; Form 540NR, line 91; or Form 540 2EZ, line 27.