Part 2 of the form includes information about the coverage offered to you by your employer, the affordability
of the coverage offered, and the reason why you were or were not offered coverage by your employer. The
information must be reported on a month-by-month basis unless the information is the same for all 12 months.

Line 15 is used to report your share of the lowest-cost monthly premium for self-only qualifying coverage.
The amount reported on line 15 may not be the amount you paid for coverage if, for example, you chose
to enroll in more expensive coverage such as family coverage. Line 15 will show an amount only if code
1B, 1C, 1D, or 1E is entered on line 14. If you were offered coverage but not required to contribute any
amount towards the premium, this line will report a “0.00” for the amount.