Section 6912 - Exemption Applications(a) The Exchange shall use an exemption application to collect the applicant's information necessary to determine the applicant's eligibility for religious conscience and hardship exemptions.(b) To apply for a religious conscience or hardship exemption, an applicant or an application filer shall submit all information, documentation, and declarations required on the application, as specified in subdivisions (c), (d), (e), and (f) of this section, and shall sign and date the application.(c) An applicant or an application filer shall provide the following information on the applicable exemption application:(1) The applicant's full name (first, middle, if applicable, and last name).(2) The applicant's home and mailing address, if different from home address, the applicant's county of residence, and telephone number(s). For an applicant who does not have a home address, only a mailing address shall be provided.(3) The applicant's email address, if the applicant chooses to get correspondence via email from the Exchange.(4) The applicant's preferred written and spoken language.(5) The applicant's date of birth.(6) The applicant's Social Security Number or Individual Taxpayer Identification Number, if one has been issued to the applicant.(7) The applicant's gender.(8) For each individual included on the applicant's state tax return, including the applicant and the applicant's spouse or domestic partner, the individual's relationship to the applicant, the individual's full name, date of birth, Social Security Number or Individual Taxpayer Identification Number, if the individual has one, gender, and whether the individual wants an exemption.(d) For a religious conscience exemption, as specified in Section 6914(b), an applicant or an application filer shall provide the following information on the religious conscience exemption application in addition to the information specified in subdivision (c) of this section:(1) The year for which the applicant or any individual in the applicant's tax household is requesting the exemption.(2) Whether the applicant or any individual in the applicant's tax household is a member of a recognized religious sect or division described in Section 1402(g)(1) of the Internal Revenue Code (26 USC § 1402(g)(1)) and adheres to the established tenets or teachings of such sect or division.(3) Whether the applicant or any individual in the applicant's tax household has an approved IRS Form 4029 ("Application for Exemption from Social Security and Medicare Taxes and Waiver of Benefits") with required signatures. If so, a copy of the approved form shall be submitted with the application.(4) Whether the applicant or any individual in the applicant's tax household is a member of a religious sect or division that is not described in Section 1402(g)(1) of the Internal Revenue Code (26 USC § 1402(g)(1)), relies solely on a religious method of healing, and the acceptance of medical health services would be inconsistent with the religious beliefs of the individual. If so, an attestation signed by the applicant that the member has not received medical health services during the preceding taxable year shall be submitted with the application.(5) The full name and address of the religious sect or division the applicant or any individual in the applicant's tax household is a member of and the date they became a member.(e) For a general hardship exemption, as specified in Section 6914(c), an applicant or an application filer shall provide the following information on the general hardship exemption application in addition to the information specified in subdivision (c) of this section:(1) The type of hardship.(2) The tax year for which the hardship exemption is requested.(3) The start and end dates for the hardship.(f) For an affordability hardship exemption, as specified in Section 6914(d), an applicant or an application filer shall provide the following information on the affordability hardship exemption application in addition to the information specified in subdivision (c) of this section: (1) The year and months the applicant requests the exemption.(2) Whether the applicant has been offered employer-sponsored health coverage.(3) Documentation of the cost of the premium for the employer-sponsored coverage for the applicant and any covered family members and whether the employer-sponsored coverage meets the minimum value standards, specified in 45 CFR Section 156.145 (February 27, 2015), hereby incorporated by reference.(4) The applicant's projected household income from all sources for the year the applicant has requested the exemption, including tax-exempt foreign earned income and tax-exempt income from interest that the applicant receives or accrues during the taxable year, if any, and proof of such income. If self-employed, the amount of net income. The projected household income does not include income from child support payments, veteran's payments, and Supplemental Security Income/State Supplementary Payment (SSI/SSP).(5) The applicant's expected type and amount of the tax deductions that the applicant is allowed to deduct from the applicant's taxable gross income when calculating the applicant's adjusted gross income on the applicant's federal income tax return.(6) Whether the applicant intends to file federal and state income tax returns for the year for which the applicant is requesting an exemption, and if so, the applicant's expected tax-filing status.(7) Whether the applicant is enrolled in minimum essential coverage through any government sponsored programs, as defined in Section 5000A(f)(1)(A) of the Internal Revenue Code (26 USC § 5000A(f)(1)(A)), or is eligible for full-scope Medi-Cal or free Medicare Part A.(8) The applicant's status as a U.S. Citizen or U.S. National, or the following information if the applicant is not a U.S. Citizen or U.S. National and attests to having lawful presence status:(A) The applicant's immigration status;(B) The applicant's immigration document type, identification number, country of issuance, expiration date, and the applicant's name as it appears on the document;(C) Whether the applicant has lived in the U.S. since 1996; and(D) Whether the applicant, or the applicant's spouse or parent, is a veteran or an active-duty member of the U.S. military.(9) Whether the applicant is pregnant, and if so, the number of babies expected and the expected delivery date.(10) Whether the applicant is 18 to 20 years old and a full-time student.(11) Whether the applicant is 18 to 26 years old and lived in foster care on the applicant's 18th birthday or whether the applicant was in foster care and enrolled in Medicaid in any state.(12) Whether the applicant is 18 years old or younger, and if so, the number of parents living with the applicant.(13) Whether the applicant lives with at least one child under the age of 19 and is the primary person taking care of this child.(14) Whether the applicant is incarcerated.(15) Whether the applicant is a primary tax filer or a tax dependent. If the applicant is a tax dependent, the non-applicant primary tax filer shall provide the information in subdivision (f)(1) through (14) of this section, except for the information in subdivision (f)(8).(16) For any other individuals seeking an exemption on the applicant's exemption application, all of the information in subdivision (f)(1) through (15) of this section.(g) If the applicant designates an authorized representative, the applicant shall provide the authorized representative's name and address, and the applicant's signature authorizing the designated representative to act on the applicant's behalf for the exemption application, eligibility and enrollment, and appeals process, if applicable.(h) An applicant or an application filer shall declare under penalty of perjury that the applicant or application filer: (1) Understood all questions on the application and gave true and correct answers to the best of the applicant's or application filer's personal knowledge.(2) Knows that if the applicant or application filer does not tell the truth on the exemption application, there may be a civil or criminal penalty for perjury pursuant to Penal Code Section 126.(3) Knows that the information provided on the exemption application shall only be used for the purpose of determining exemption eligibility for the individuals listed on the application who are requesting an exemption, and that the Exchange shall keep such information private in accordance with the applicable federal and State privacy and security laws.(4) Understands that the Exchange shall not discriminate against the applicant or anyone on the application because of race, color, national origin, religion, age, sex, sexual orientation, gender identity, or disability, and that the applicant may make a complaint of discrimination through the U.S. Department of Health and Human Services, Office for Civil Rights.Cal. Code Regs. Tit. 10, § 6912
Note: Authority cited: Sections 100504 and 100725, Government Code. Reference: Sections 100502 and 100715, Government Code; 26 USC Section 5000A; and 45 CFR Sections 155.605, 155.610 and 156.145.
Note: Authority cited: Sections 100504 and 100725, Government Code. Reference: Sections 100502 and 100715, Government Code; 26 USC Section 5000A; 45 CFR Sections 155.605, 155.610 and 156.145.
1. New section filed 10-7-2019 as a deemed emergency pursuant to Government Code section 100725(c); operative 1/1/2020 (Register 2019, No. 41). A Certificate of Compliance must be transmitted to OAL by 1-1-2025 pursuant to Government Code section 100725 or emergency language will be repealed by operation of law on the following day.
2. New section refiled 5-11-2020 as a deemed emergency pursuant to Government Code section 100725(c), including amendment of section and Note; operative 5/11/2020 (Register 2020, No. 20). A Certificate of Compliance must be transmitted to OAL by 1-1-2025 pursuant to Government Code section 100725or emergency language will be repealed by operation of law on the following day.
3. Certificate of Compliance as to 5-11-2020 order, including amendment of subsections (b), (c)(2), (d)(2) and (f)(6) transmitted to OAL 5-20-2024 and filed 7-2-2024; amendments effective 7/2/2024 pursuant to Government Code section 11343.4(b)(3) (Register 2024, No. 27).