3853: Health Coverage Exemption and Individual Shared Responsibility Penalty (2025)
California · FTB · Used for tax years 2025
California Form 3853 reports health coverage, coverage exemptions, and the Individual Shared Responsibility Penalty for 2025. It lists applicable household members and attaches to California Form 540, Form 540NR, or Form 540 2EZ.
Who files this form
California Form 3853 for tax year 2025 covers health coverage exemptions and the Individual Shared Responsibility Penalty. Attach it to California Form 540, Form 540NR, or Form 540 2EZ.
Complete Part III if you or a member of your applicable household are reporting coverage or claiming exemptions for the tax year. Part II has a checkbox for claiming a household 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 for the fields on the form:
- 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 (Modified AGI).
- Any Exemption Certificate Numbers (ECNs) granted by the Marketplace.
- Coverage and exemption codes for the full year or individual months, as applicable.
- Your Individual Shared Responsibility Penalty amount for Part IV.
The form does not name any supporting documents you must provide.
How to file
Attach Form 3853 to your California Form 540, Form 540NR, or Form 540 2EZ.
Enter the penalty from Part IV, line 1, on the appropriate return line:
- Form 540, line 92.
- Form 540NR, line 91.
- Form 540 2EZ, line 27.
The provided form does not give a mailing address or e-filing directions.
Common mistakes
- Leaving household members out of Part I. The form specifically says to list all members of your applicable household, whether or not they have an exemption or a Marketplace-granted Exemption Certificate Number (ECN).
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 a Marketplace-granted ECN.
Where do I claim an exemption based on household income?
Check the box in Part II if you are claiming a coverage exemption because your applicable household income or gross income is below the filing threshold. The form does not provide 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 amount from Part IV, line 1, on Form 540, line 92; Form 540NR, line 91; or Form 540 2EZ, line 27.