Form FTB 3853
Use this form when you file your California state taxes to report that you had health insurance, claim an exemption from the insurance requirement or calculate any penalty you owe.
What Form FTB 3853 Is For
Form FTB 3853, Health Coverage Exemptions and Individual Shared Responsibility Penalty, is the form you file with your California state income tax return to:
- Report who in your tax household had health insurance during the year.
- Claim exemptions from the state requirement to have health insurance, if you’re eligible.
- See if you owe a penalty for not having health insurance, and if so, how much.
You may need to file this form if:
- You or anyone in your tax household didn’t have qualifying health insurance for one or more months of the year.
- You’re claiming an exemption from the state health insurance requirement.
- Covered California approved an exemption for you and gave you an exemption certificate number (ECN) to enter on the form.
- The form or your tax-filing software directs you to complete a Marketplace Coverage Affordability Worksheet.
For a broader overview of penalties and exemptions, see Penalty Details and Exemptions.
How do I get Form FTB 3853?
If you file online, this form is typically automatically generated for you through your tax software.
If you’re filing on paper, download Form FTB 3853 (PDF) from the California Franchise Tax Board (FTB). For line-by-line instructions, view the FTB 3853 Instructions (PDF)
What to Gather Before You Start
Before completing Form FTB 3853, gather the following:
- Your California state tax return or tax software instructions.
- Information about who in your household had health insurance and for which months.
- Exemption certificate numbers (ECNs), if Covered California approved an exemption for you or a household member.
- If your form directs you to the Marketplace Coverage Affordability Worksheet, you will need your ZIP code, county (if needed), total household income for the tax year, household size and ages of household members.
Complete the Affordability Worksheet
If Form FTB 3853 directs you to complete the Marketplace Coverage Affordability Worksheet, follow these steps to find the plan premium amounts you need.
Open Shop and Compare.
Go to our Shop and Compare Tool to get started.
Enter your household information.
While adding household members, select Needs Coverage for each person. For this worksheet only, do not select pregnant, blind or disabled. These checkboxes change your plan results in a way that won't work for this worksheet.
Find the lowest-cost Bronze plan.
Sort results by Lowest premium and filter by Bronze only. Find the first Bronze plan listed and select Plan Details. Scroll to the “Monthly Premium” section and find “Monthly premium after savings.” Enter this amount on Line 1 of the worksheet.
Find the second-lowest-cost Silver plan.
Sort results by Lowest premium and filter by Silver only. Find the second Silver plan listed and select Plan Details. Scroll to the “Monthly Premium” section and find “Monthly premium before savings.” Enter this amount on Line 10 of the worksheet.
After You Complete the Form
Form FTB 3853 will show whether you owe a penalty for any months you or your household members were without qualifying health insurance. If you owe a penalty, it will be included in your total California state tax due when you file. If you claimed a valid exemption, the form confirms your exemption for the year.
Enter your exemption certificate number (ECN) on the form where indicated if you have one. This confirms that Covered California reviewed and approved your exemption. You don’t need to submit additional documentation with your return.
For questions about your penalty amount or help completing your tax return, contact the California Franchise Tax Board (FTB) or a tax professional. Covered California cannot provide tax advice.
Frequently Asked Questions
Related Information
Use these resources if you need broader information about penalties, exemptions or help understanding your options.