Exemption forms
All completed applications must be printed, signed by the tax filer for your household, and mailed to the Marketplace. You may need to submit copies of documents with your application.
Step 1: Get the correct form for your situation
Select the exemption type you want:
You can fill out the form online. When you're done, you'll download your application to create the PDF with your information and print it.
Or, get the paper hardship form (PDF, 436 KB) to fill it out.
Download the correct form for your state
When you select a form below, it will automatically download to your computer.
- Affordability exemption application form (PDF, 893 KB) if you live in:
- Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Hawaii, Indiana, Iowa, Kansas, Louisiana, Michigan, Mississippi, Missouri, Montana, Nebraska, New Hampshire, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, South Carolina, South Dakota, Tennessee, Texas, Utah, West Virginia, Wisconsin, Wyoming
- Spanish affordability exemption application form (PDF, 923 KB)
- Affordability exemption application form (PDF, 794 KB) if you live in:
- Colorado, Georgia, Idaho, Illinois, Kentucky, Maine, Massachusetts, Minnesota, Nevada, New Jersey, New Mexico, New York, Pennsylvania, Rhode Island, Vermont, Virginia, Washington
- Spanish affordability exemption application form (PDF, 777 KB)
Step 2: Open the form in Adobe Reader
- If you don't have Adobe Reader version 8 or higher, download the latest version for free.
- Locate the form on your computer. If you can't find it, check your "Downloads" folder.
- Select and open the document.
Step 3: Complete the form
Read the form instructions and fill it out. When you're done:
- Save your changes—Save the completed form to a folder or place on your computer where it will be easy to find later.
- Print and sign the application.
- Gather copies of any documents (not originals) as directed on the form.
- Mail your completed application and copies of any documents to:
Health Insurance Marketplace
Attn: Exemption Processing
465 Industrial Blvd.
London, KY 40741
If you're having trouble opening the form or filling it out, contact the Marketplace Call Center.