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Application for Exemption for American Indians and Alaska Natives and Other Individuals who are Eligible to Receive Services from an Indian Health Care Provider THINGS TO KNOW Form Approved OMB No

09381190 Use this application to apply for an exemption from the shared responsibility payment Starting in 2014 every person needs to have health coverage or make a payment on their federal income tax return called the shared responsibility payment

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Application for Exemption for American Indians and Alaska Natives and Other Individuals who are Eligible to Receive Services from an Indian Health Care Provider THINGS TO KNOW Form Approved OMB No






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