This form contains 16 fields organized into 6 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name Type Description
Business Income
4 Text
Enter the total net profit from your business as reported on Schedule C or Schedule F.
11 11 Enter your Medicare wages (box 5 of Form W-2) from an S corporation in which you are a more--than-2% shareholder and in which the insurance plan is established Text
Enter your Medicare wages (box 5 of Form W-2) from an S corporation in which you are a more-than-2% shareholder and in which the insurance plan is established.
Calculations
6 Divide line 4 by line 5 6 Text
Divide the amount on line 4 by the amount on line 5 and enter the result here.
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Enter any additional amounts that need to be included in the calculation.
8 80 Subtract line 7 from line 4 8 Text
Subtract the amount on line 7 from the amount on line 4 and enter the result here.
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Enter any additional amounts that need to be included in the calculation.
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Enter any additional amounts that need to be included in the calculation.
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Enter any additional amounts that need to be included in the calculation.
Subtract line 12 from line 10 or 11, whichever applies 13 13 Text
Subtract the amount on line 12 from the amount on line 10 or 11, whichever applies, and enter the result here.
Deduction Details
14 deduction on Schedule A (Form 1040) 14 Text
Enter the amount of deduction you are claiming on Schedule A (Form 1040) for health insurance premiums paid. This should be the total amount you are deducting for yourself, your spouse, and your dependents.
Health Insurance Payments
1 Text
Enter the total amount of health insurance premiums paid for yourself, your spouse, and dependents.
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Enter any additional health insurance premiums paid that are not included in the previous field.
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Enter the total amount of long-term care insurance premiums paid for yourself, your spouse, and dependents.
Other Income
schedules 5 01 Text
Enter the total amount from Schedule 5, line 1.
Personal Information
Name(s) shown on return Text
Enter the name(s) exactly as shown on your tax return (Form 1040, 1040-SR, or 1040-NR).
Your taxpayer identification number Text
Enter your taxpayer identification number (TIN), which can be your Social Security Number (SSN) or Individual Taxpayer Identification Number (ITIN).
Max length: 11 characters