1040 U.S.

Individual Income Tax Return 2023

Form Department of the Treasury—Internal Revenue Service

OMB No. 1545-0074 IRS Use Only—Do not write or staple in this space.

For the year Jan. 1–Dec. 31, 2023, or other tax year beginning , 2023, ending , 20 See separate instructions.
Your first name and middle initial Last name Your social security number
Mackenzie Still 030 88 0175
If joint return, spouse’s first name and middle initial Last name Spouse’s social security number

Home address (number and street). If you have a P.O. box, see instructions. Apt. no. Presidential Election Campaign
35 School House Rd Check here if you, or your
City, town, or post office. If you have a foreign address, also complete spaces below. State ZIP code spouse if filing jointly, want $3
to go to this fund. Checking a
Eastham MA 026423014 box below will not change
Foreign country name Foreign province/state/county Foreign postal code your tax or refund.
You Spouse

Filing Status Single Head of household (HOH)

Married filing jointly (even if only one had income)
Check only
one box. Married filing separately (MFS) Qualifying surviving spouse (QSS)
If you checked the MFS box, enter the name of your spouse. If you checked the HOH or QSS box, enter the child’s name if the
qualifying person is a child but not your dependent:

Digital At any time during 2023, did you: (a) receive (as a reward, award, or payment for property or services); or (b) sell,
Assets exchange, or otherwise dispose of a digital asset (or a financial interest in a digital asset)? (See instructions.) Yes No
Standard Someone can claim: You as a dependent Your spouse as a dependent
Deduction Spouse itemizes on a separate return or you were a dual-status alien

Age/Blindness You: Were born before January 2, 1959 Are blind Spouse: Was born before January 2, 1959 Is blind
Dependents (see instructions): (2) Social security (3) Relationship (4) Check the box if qualifies for (see instructions):
(1) First name Last name number to you Child tax credit Credit for other dependents
If more
than four
dependents,
see instructions
and check
here . .

Income 1a Total amount from Form(s) W-2, box 1 (see instructions) . . . . . . . . . . . . . 1a 6,407.
b Household employee wages not reported on Form(s) W-2 . . . . . . . . . . . . . 1b
Attach Form(s)
W-2 here. Also c Tip income not reported on line 1a (see instructions) . . . . . . . . . . . . . . 1c
attach Forms d Medicaid waiver payments not reported on Form(s) W-2 (see instructions) . . . . . . . . 1d
W-2G and
1099-R if tax e Taxable dependent care benefits from Form 2441, line 26 . . . . . . . . . . . . 1e
was withheld. f Employer-provided adoption benefits from Form 8839, line 29 . . . . . . . . . . . 1f
If you did not g Wages from Form 8919, line 6 . . . . . . . . . . . . . . . . . . . . . 1g
get a Form
W-2, see
h Other earned income (see instructions) . . . . . . . . . . . . . . . . . . 1h 0.
instructions. i Nontaxable combat pay election (see instructions) . . . . . . . 1i
z Add lines 1a through 1h . . . . . . . . . . . . . . . . . . . . . . 1z 6,407.
Attach Sch. B 2a Tax-exempt interest . . . 2a b Taxable interest . . . . . 2b
if required. 3a Qualified dividends . . . 3a b Ordinary dividends . . . . . 3b
4a IRA distributions . . . . 4a b Taxable amount . . . . . . 4b
Standard
Deduction for— 5a Pensions and annuities . . 5a b Taxable amount . . . . . . 5b
• Single or 6a Social security benefits . . 6a b Taxable amount . . . . . . 6b
Married filing
separately, c If you elect to use the lump-sum election method, check here (see instructions) . . . . .
$13,850 7 Capital gain or (loss). Attach Schedule D if required. If not required, check here . . . . . 7
• Married filing
jointly or 8 Additional income from Schedule 1, line 10 . . . . . . . . . . . . . . . . . 8
Qualifying
surviving spouse, 9 Add lines 1z, 2b, 3b, 4b, 5b, 6b, 7, and 8. This is your total income . . . . . . . . . . 9 6,407.
$27,700 10 Adjustments to income from Schedule 1, line 26 . . . . . . . . . . . . . . . 10
• Head of
household, 11 Subtract line 10 from line 9. This is your adjusted gross income . . . . . . . . . . 11 6,407.
$20,800
• If you checked
12 Standard deduction or itemized deductions (from Schedule A) . . . . . . . . . . 12 6,807.
any box under 13 Qualified business income deduction from Form 8995 or Form 8995-A . . . . . . . . . 13
Standard
Deduction, 14 Add lines 12 and 13 . . . . . . . . . . . . . . . . . . . . . . . . 14 6,807.
see instructions.
15 Subtract line 14 from line 11. If zero or less, enter -0-. This is your taxable income . . . . . 15 0.
For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions. Form 1040 (2023)
Form 1040 (2023) Page 2

Tax and 16 Tax (see instructions). Check if any from Form(s): 1 8814 2 4972 3 . . 16 0.
Credits 17 Amount from Schedule 2, line 3 . . . . . . . . . . . . . . . . . . . . 17
18 Add lines 16 and 17 . . . . . . . . . . . . . . . . . . . . . . . . 18 0.
19 Child tax credit or credit for other dependents from Schedule 8812 . . . . . . . . . . 19
20 Amount from Schedule 3, line 8 . . . . . . . . . . . . . . . . . . . . 20
21 Add lines 19 and 20 . . . . . . . . . . . . . . . . . . . . . . . . 21
22 Subtract line 21 from line 18. If zero or less, enter -0- . . . . . . . . . . . . . . 22 0.
23 Other taxes, including self-employment tax, from Schedule 2, line 21 . . . . . . . . . 23 0.
24 Add lines 22 and 23. This is your total tax . . . . . . . . . . . . . . . . . 24 0.
Payments 25 Federal income tax withheld from:
a Form(s) W-2 . . . . . . . . . . . . . . . . . . 25a
b Form(s) 1099 . . . . . . . . . . . . . . . . . . 25b
c Other forms (see instructions) . . . . . . . . . . . . . 25c
d Add lines 25a through 25c . . . . . . . . . . . . . . . . . . . . . . 25d
If you have a 26 2023 estimated tax payments and amount applied from 2022 return . . . . . . . . . . 26
qualifying child, 27 Earned income credit (EIC) . . . . . . . . . . . .No. . 27
attach Sch. EIC.
28 Additional child tax credit from Schedule 8812 . . . . . . . . 28
29 American opportunity credit from Form 8863, line 8 . . . . . . . 29
30 Reserved for future use . . . . . . . . . . . . . . . 30
31 Amount from Schedule 3, line 15 . . . . . . . . . . . . 31
32 Add lines 27, 28, 29, and 31. These are your total other payments and refundable credits . . 32
33 Add lines 25d, 26, and 32. These are your total payments . . . . . . . . . . . . 33
Refund 34 If line 33 is more than line 24, subtract line 24 from line 33. This is the amount you overpaid . . 34
35a Amount of line 34 you want refunded to you. If Form 8888 is attached, check here . . . . 35a
Direct deposit? b Routing number X X X X X X X X X c Type: Checking Savings
See instructions.
d Account number X X X X X X X X X X X X X X X X X
36 Amount of line 34 you want applied to your 2024 estimated tax . . . 36
Amount 37 Subtract line 33 from line 24. This is the amount you owe.
You Owe For details on how to pay, go to www.irs.gov/Payments or see instructions . . . . . . . . 37 0.
38 Estimated tax penalty (see instructions) . . . . . . . . . . 38
Third Party Do you want to allow another person to discuss this return with the IRS? See
Designee instructions . . . . . . . . . . . . . . . . . . . . . Yes. Complete below. No
Designee’s Phone Personal identification
name no. number (PIN)

Sign Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge and
belief, they are true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Here Your signature Date Your occupation If the IRS sent you an Identity
Protection PIN, enter it here
Joint return? student (see inst.)
See instructions. Spouse’s signature. If a joint return, both must sign. Date Spouse’s occupation If the IRS sent your spouse an
Keep a copy for Identity Protection PIN, enter it here
your records. (see inst.)

Phone no. (508)237-2638 Email address

Preparer’s name Preparer’s signature Date PTIN Check if:
Paid Self-employed
Preparer
Firm’s name Self-Prepared Phone no.
Use Only
Firm’s address Firm’s EIN
Go to www.irs.gov/Form1040 for instructions and the latest information. BAA REV 02/16/24 Intuit.cg.cfp.sp Form 1040 (2023)
 2023 Form 1
MA23001011555
Massachusetts Resident Income Tax Return
FOR FULL YEAR RESIDENTS ONLY
For the year January 1–December 31, 2023 or other taxable

Year beginning Ending

MACKENZIE STILL 030880175

35 SCHOOL HOUSE RD EASTHAM MA 026423014

Fill in if: Amended return Other jurisdiction change Enter date of change
Federal amendment Amended return due to IRS BBA Partnership Audit
State Election Campaign Fund: $1 You $1 Spouse TOTAL XX
Fill in if veteran of Operations Enduring Freedom, Iraqi Freedom, Noble Eagle or Sinai Peninsula You Spouse
Taxpayer deceased You Spouse
Fill in if under age 18 You Spouse
Fill in if name change You Spouse
a. Total federal income 6407 Fill in if noncustodial parent
b. Federal adjusted gross income 6407 Fill in if filing Schedule TDS
1. Filing status (select one only): X Single Fill in if filing Schedule FCI
Married filing jointly Fill in if reporting crypto currency
Married filing separate return NRA
Head of household You are a custodial parent who has released claim to exemption for child(ren)
2. Exemptions
a. Personal exemptions 2a 4400
b. Number of dependents. (Do not include yourself or your spouse.) Enter number × $1,000 = 2b
c. Age 65 or over before 2024 You + Spouse = × $700 = 2c XXXXX
d. Blindness You + Spouse = × $2,200 = 2d XXXXX
e. Medical/dental 2e
f. Adoption 2f
g. Total exemptions. Add items 2a through 2f. Enter here and on line 18 2g 4400
SIGN HERE. Under penalties of perjury, I declare that to the best of my knowledge and belief this return and enclosures are true, correct and complete.
Your signature Date Spouse’s signature Date

508-237-2638
PRIVACY ACT NOTICE AVAILABLE UPON REQUEST

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 2023 Form 1, pg. 2
MA23001021555
Massachusetts Resident Income Tax Return
030880175

3. Wages, salaries, tips 3 6407

4. Taxable pensions and annuities 4
5. Mass. bank interest: a. – b. exemption =5
6a. Business/profession income/loss 6a
6b. Farming income/loss 6b
7. Rental, royalty and REMIC, partnership, S corp., trust income/loss 7
8a. Unemployment 8a XXXXXXXX
8b. Mass. lottery winnings 8b
9. Other income from Schedule X, line 7 9
10. TOTAL 5.0% INCOME 10 6407
11a. Amount paid to Soc. Sec. Medicare, R.R., U.S. or Mass. Retirement 11a 175
11b. Amount your spouse paid to Soc. Sec., Medicare, R.R., U.S. or Mass. Retirement 11b XXXXX
12. Reserved for future use 12 XXXXX
13. Reserved for future use 13 XXXXX

14. Rental deduction. a. XXXXXXX ÷ 2 = 14 XXXXX

15. Other deductions from Schedule Y, line 19 15
16. Total deductions. Add lines 11 through 15 16 175
17. 5.0% INCOME AFTER DEDUCTIONS. Subtract line 16 from line 10. Not less than “0” 17 6232
18. Exemption amount 18 4400
19. 5.0% INCOME AFTER EXEMPTIONS. Subtract line 18 from line 17. Not less than “0” 19 1832
20. INTEREST AND DIVIDEND INCOME 20
21. TOTAL TAXABLE 5.0% INCOME. Add lines 19 and 20 21 1832
22. TAX ON 5.0% INCOME. Note: If choosing the optional 5.85% tax rate, fill in and multiply line 21 and the
amount in Schedule D, line 21 by .0585 22 91
23. INCOME FROM SCHEDULE B. Not less than “0.”
a. × .085 = 23a
b. × .12 = 23b
TOTAL TAX ON INCOME FROM SCHEDULE B. Add lines 23a and 23b 23

BE SURE TO INCLUDE THIS PAGE WITH FORM 1, PAGE 1

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 2023 Form 1, pg. 3
MA23001031555
Massachusetts Resident Income Tax Return
030880175

24. TAX ON LONG-TERM CAPITAL GAINS. Not less than “0.” Fill in if filing Schedule D-IS 24
Fill in if any excess exemptions were used in calculating lines 20, 23 or 24
25. Credit recapture amount (from Credit Recapture Schedule) 25
26. Additional tax on installment sale 26
27. If you qualify for No Tax Status, fill in and enter “0” on line 28 X
28. TOTAL INCOME TAX.
a. Income tax. Add lines 22 through 26 28a
b. 4% Surtax. (from Schedule 4% Surtax, line 7) 28b
c. Total tax. Add lines 28a and 28b 28
29. Limited Income Credit 29
30. Income tax due to another state or jurisdiction 30
31. Other credits from Credit Manager Schedule 31
32. INCOME TAX AFTER CREDITS. Subtract the total of lines 29 through 31 from line 28. Not less than “0” 32
33. Voluntary Contributions
a. Endangered Wildlife Conservation 33a
b. Organ Transplant Fund 33b
c. Massachusetts Public Health HIV and Hepatitis Fund 33c
d. Massachusetts U.S. Olympic Fund 33d
e. Massachusetts Military Family Relief Fund 33e
f. Homeless Animal Prevention and Care 33f
Total. Add lines 33a through 33f 33
34. Use tax due on Internet, mail order and other out-of-state purchases 34
35. Health care penalty a. You XXXXX + b. Spouse XXXXX 35 XXXXXXX
36. Amended return only. Overpayment from original return 36
37. INCOME TAX AFTER CREDITS PLUS CONTRIBUTIONS AND USE TAX. Add lines 32 through 36 37
38. a. Massachusetts income tax withheld from Form(s) W-2 38a 57
b. Massachusetts income tax withheld from Form(s) 1099 38b
c. Massachusetts income tax withheld from other forms 38c
Total. Add lines 38a through 38c 38 57

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 2023 Form 1, pg. 4
MA23001041555
Massachusetts Resident Income Tax Return
030880175

39. 2022 overpayment applied to your 2023 estimated tax 39

40. 2023 Massachusetts estimated tax payments 40
41. Payments made with extension 41
42. Amended return only. Payments made with original return. Not less than “0” 42
43. Earned Income Credit. a. Number of qualifying children b. Amount from U.S. return XXXXX × .40 = 43 XXXXX
Note: You cannot claim the Earned Income Credit if your filing status is married filing separately unless you qualify
for an exception (see instructions). Fill in if you qualify for this exception
44. Senior Circuit Breaker Credit 44 XXXXX
45. Reserved for future use 45 XXXX
46. Child and Family Tax Credit

a. × $310 = 46 XXXXX
47. Other Refundable Credits 47
48. Total Refundable Credits. Add lines 43 through 47 48
49. Excess Paid Family Leave Withholding 49
50. TOTAL. Add lines 38 through 42 and lines 48 and 49 50 57
51. Overpayment. Subtract line 37 from line 50 51 57
52. Amount of overpayment you want applied to your 2024 estimated tax 52
53. Refund. Subtract line 52 from line 51. Mail to: Massachusetts DOR, PO Box 7000, Boston, MA 02204 53 57
Direct deposit of refund. Type of account X checking
savings
RTN # 211371078 account # 831167238
54. Tax due. Pay online at www.mass.gov/dor/payonline. Mail to: Mass. DOR, PO Box 7003, Boston, MA 02204 54
Interest Penalty M-2210 amt. EX enclose
Form M-2210

May the Department of Revenue discuss this return with the preparer shown here?
I do not want preparer to file my return electronically (this may delay your refund) Paid preparer’s
Print paid preparer’s name Date Check if self-employed SSN/PTIN

Paid preparer’s signature Paid preparer’s phone Paid preparer’s EIN

SELF PREPARED
BE SURE TO INCLUDE THIS PAGE WITH FORM 1, PAGE 1

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2023 Schedule INC
MA23INC011555

MACKENZIE STILL 030880175

Form W-2 and 1099 Information
A. FEDERAL ID NUMBER B. STATE TAX WITHHELD C. STATE WAGES/INCOME D. TAXPAYER SS WITHHELD E. SPOUSE SS WITHHELD F. SOURCE OF WITHHOLDING

042962063 57 1233 94 W2
046001345 5174 81 W2

TOTALS 57 6407 175

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 2023 Schedule HC
MA23029011555
Schedule HC, Health Care Information, must be completed by all
full-year residents and certain part-year residents (see instructions).
Note: Schedule HC must be enclosed with your Form 1 or Form
1-NR/PY. Failure to do so will delay the processing of your return.
MACKENZIE STILL 030880175

1a. Date of birth 09072005 1b. Spouse’s date of birth 1c. Family size 1
2. Federal adjusted gross income 2 6407
3. Indicate the time period that you were enrolled in a Minimum Creditable Coverage (MCC) health insurance plan(s). The Form MA 1099-HC from your
insurer will indicate whether your insurance met MCC requirements. Note: MassHealth, Medicare, and health coverage for U.S. Military, including
Veterans Administration and Tri-Care, meet the MCC requirements. If you did not receive a Form MA 1099-HC from your insurer, or you had insurance
that did not meet MCC requirements, see the special section on MCC requirements in the instructions.

See instructions if, during 2023, you turned 18, you 3a You: X Full-year MCC Part-year MCC No MCC/None
were a part-year resident or a taxpayer was deceased. 3a Spouse: Full-year MCC Part-year MCC No MCC/None
If you filled in the full-year or part-year MCC oval, go to line 4. If you filled in No MCC/None, go to line 6.

4. Indicate the health insurance plan(s) that met the Minimum Creditable Coverage (MCC) requirements in which you were enrolled in 2023, as
shown on Form MA 1099-HC (check all that apply). If you did not receive this form, fill in line(s) 4f and/or 4g and see instructions. Fill in if you were
enrolled in private insurance and MassHealth or Commonwealth Care and enter your private insurance information in line(s) 4f and/or 4g and go
to line 5.
4a. Private insurance, including ConnectorCare (completes line(s) 4f and/or 4g below) X You Spouse
4b. MassHealth. Fill in and go to line 5 You Spouse
4c. Medicare (including a replacement or supplemental plan). Fill in and go to line 5 You Spouse
4d. U.S. Military (including Veterans Administration and Tri-Care). Fill in and go to line 5 You Spouse
4e. Other program (enter the program name(s) only in lines 4f and/or 4g below). Note: Health Safety Net You Spouse
is not considered insurance or minimum creditable coverage.

4f. Your Health Insurance. Complete if you answered line(s) 4a or 4e and go to line 5.
UNITED HEALTHCARE 960000161 982841484

4g. Spouse Health Insurance. Complete if you answered line(s) 4a or 4e and go to line 5.

5. If you had health insurance that met MCC requirements for the full-year, including private insurance, MassHealth, Commonwealth Care or ConnectorCare,
you are not subject to a penalty. Skip the remainder of this schedule and continue completing your tax return. Other wise, go to line 6.

If you had Medicare (including a replacement or supplemental plan), U.S. Military (including Veterans Administration and Tri-Care), or other government
insurance at any point during 2023, you are not subject to a penalty. Skip the remainder of this schedule and continue completing your tax return.
Otherwise, go to line 6.

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 2023 Schedule HC, pg. 2
030880175 MA23029021555

You might be eligible for low- or no-cost health insurance coverage.

If you (and/or your spouse, if married filing jointly) do not have health insurance coverage, you might be eligible for health insurance coverage programs made
available by the Commonwealth of Massachusetts. By filling in the oval below, you authorize DOR to share information from your tax return and attached schedules
with the Health Connector. If you are married filing jointly, both spouses must check the box for the Health Connector to receive all of your information. The Health
Connector will assess your eligibility for those coverage options, including low- or no-cost coverage, and contact you with information. See instructions.
You: I authorize DOR to share this tax return including attached schedules with the Massachusetts Health Connector for the purpose of assessing
my eligibility for insurance affordability programs and contacting me with information about the same.
Spouse: I authorize DOR to share this tax return including attached schedules with the Massachusetts Health Connector for the purpose of assessing
my eligibility for insurance affordability programs and contacting me with information about the same.
Your Health Insurance
6. Was your income in 2023 at or below 150% of the federal poverty level? 6 Yes No
If you answer Yes, you are not subject to a penalty in 2023. Skip the remainder of this schedule and complete your tax return. If you answer No and you were enrolled
in a health insurance plan that met the MCC requirements for part, but not all, of 2023, go to line 7. If you answer No and you had no insurance or you were enrolled
in a plan that did not meet the MCC requirements during the period that the mandate applied, go to line 8a.
7. Complete this section only if you, and/or your spouse if married filing jointly, were enrolled in a health insurance plan(s) that met the Minimum Creditable
Coverage (MCC) requirements for part, but not all of 2023. Fill in below the months that met the MCC requirements, as shown on Form MA 1099-HC. If you
did not receive this form, fill in the months you were covered by a plan that met the MCC requirements at least 15 days or more. If, during 2023, you turned
18, you were a part-year resident or a taxpayer was deceased, fill in the oval(s) below for the month(s) that met the MCC requirements during the period
that the mandate applied. See instructions.
You may only fill in the month(s) you had health insurance that met MCC requirements. If you had health insurance, but it did not meet MCC requirements,
you must skip this section and go to line 8a.

Months Covered By Health Insurance

You: Jan. Feb. March April May June July Aug. Sept. Oct. Nov. Dec.
Spouse: Jan. Feb. March April May June July Aug. Sept. Oct. Nov. Dec.
If you had four or more consecutive months either with no insurance or insurance that did not meet the MCC requirements (four or more blank months in a row),
go to line 8a. Otherwise, a penalty does not apply to you in 2023. Skip the remainder of this schedule and complete your tax return.

Religious Exemption and Certificate of Exemption

8a. Religious exemption: Are you claiming an exemption from the requirement to purchase health insurance based 8a You Yes No
on your sincerely held religious beliefs that cause you to object to substantially all forms of treatment covered by
health insurance? Spouse Yes No
If you answer Yes, go to line 8b. If you answer No, go to line 9.
8b. If you are claiming a religious exemption in line 8a, did you receive medical health care during the 2023 tax year? 8b You Yes No
Spouse Yes No
If you answer No to line 8b, skip the remainder of this schedule and continue completing your tax return. If you answer Yes to line 8b, go to line 9.
9. Certificate of exemption: Have you obtained a Certificate of Exemption issued by the Massachusetts Health 9 You Yes No
Connector for the 2023 tax year? Spouse Yes No
If you answer Yes, enter the certificate number, skip the remainder of this schedule and continue completing your tax
return. If you answer No to line 9, go to line 10.

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 2023 Schedule HC, pg. 3
MA23029031555

MACKENZIE STILL 030880175

Affordability as Determined By State Guidelines
Note: This section will require the use of worksheets and tables found in the instructions. You must complete the worksheet(s) to determine if health insurance was
affordable to you during the 2023 tax year.
10. Did your employer offer affordable health insurance that met minimum creditable coverage requirements 10 You Yes No
as determined by completing the Schedule HC Worksheet for Line 10 in the instructions? Spouse Yes No
Fill in No if your employer did not offer health insurance that met minimum creditable coverage requirements, you were not eligible for health insurance offered by
your employer, you were self-employed or you were unemployed.
11. Were you eligible for government-subsidized health insurance as determined by completing the Schedule HC 11 You Yes No
Worksheet for Line 11 in the instructions? Spouse Yes No
If you answer No, go to line 12. If you answer Yes, go to the Health Care Penalty Worksheet in the instructions to calculate your penalty amount.
12. Were you able to purchase affordable private health insurance that met minimum creditable coverage requirements 12 You Yes No
as determined by completing the Schedule HC Worksheet for Line 12 in the instructions? Spouse Yes No
If you answer No, you are not subject to a penalty. Continue completing your tax return. If you answer Yes, go to the Health Care Penalty Worksheet in the
instructions to calculate your penalty amount.

Complete Only If You Are Filing An Appeal

You must complete the Health Care Penalty Worksheet to determine your penalty amount before completing this section.
You may have grounds to appeal if you were unable to obtain affordable insurance that meets the minimum creditable coverage requirements in 2023 due to a
hardship or other circumstances. The grounds for appeal are explained in more detail in the instructions. If you believe you have grounds for appealing the penalty,
fill in the field(s) below. The appeal will be heard by the Massachusetts Health Connector. By filling in the field below, you (or your spouse if married filing jointly) are
authorizing DOR to share information from your tax return, including this schedule, with the Massachusetts Health Connector for purposes of deciding your appeal.
You will receive a follow-up letter asking you to state your grounds for appeal in writing, and submit supporting documentation. Failure to respond to
that letter within the time specified in the letter will lead to dismissal of your appeal and will result in a future assessment of a penalty. Once your
documentation is received, it will be reviewed by the Massachusetts Health Connector and you may be required to attend a hearing on your case. You will be required
to file your claims under the pains and penalties of perjury.
Note: If you are filing an appeal, make sure you have calculated the penalty amount that you are appealing, but do not assess yourself or enter a penalty amount
on your Form 1 or Form 1-NR/PY. Also, do not include any hardship documentation with your original return. You will be required to submit substantiating hardship
documentation at a later date during the appeal process.

You: I wish to appeal the penalty. I authorize DOR to share this tax return including this schedule with the Massachusetts Health Connector
for purposes of deciding this appeal.

Spouse: I wish to appeal the penalty. I authorize DOR to share this tax return including this schedule with the Massachusetts Health Connector
for purposes of deciding this appeal.

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