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  • 2025 California Form 3853 Health Coverage Exemptions and Individual . . .
    Health Coverage Exemptions and Individual Shared Responsibility Penalty Name(s) as shown on your California tax return 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 1
  • 2025 Instructions for Form FTB 3853 - Franchise Tax Board
    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
  • How to Fill Out FTB Form 3853 (w Examples) + FAQs
    California’s FTB Form 3853 is the state tax form you use to report health coverage for yourself and your household, claim any health-care exemptions, or calculate the Individual Shared Responsibility Penalty if you lacked Minimum Essential Coverage (MEC) during the tax year
  • FTB Form 3853 Health Coverage Exemptions and Individual Shared . . .
    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 Use the California Franchise Tax Board forms finder to view Form FTB 3853
  • Form 3853 Exemption Certificate Number: Apply and Enter
    Learn which exemptions require an ECN, how to apply through Covered California, and how to enter the number on Form 3853 to avoid California's health coverage penalty
  • Desktop: California Form 3853 - Health Coverage Exemptions and . . .
    The penalty for not having full-year MEC is calculated using the worksheets in the instructions for Form 3853, Health Coverage Exemptions and Individual Shared Responsibility Penalty, along with the exemption information provided in the form itself
  • Exemptions - Covered California
    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 If you disagree with our decision about your eligibility for an exemption you can file an appeal or a complaint
  • Form FTB3853 Download Fillable PDF or Fill Online Health Coverage . . .
    Download a fillable version of Form FTB3853 by clicking the link below or browse more documents and templates provided by the California Franchise Tax Board Download Fillable Form Ftb3853 In Pdf - The Latest Version Applicable For 2026
  • CA – California Form 3853 – Health Coverage Exemptions
    Form 3853 is used to calculate the Individual Shared Responsibility Penalty for any household member who did not maintain qualifying health coverage and did not qualify for an exemption
  • California Form 3853: Health Coverage Exemptions Penalty
    Learn whether you need to file California Form 3853, which health coverage exemptions apply to you, and how to calculate or dispute a penalty





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