fes. chock the apcmonate bow IRS change Date or Final NYS change Determination Final return • Ceased cpwabons Attach copy of your entire todetal Form MA) end statement snowing eiLscesition or business propeny. Engaged In a fully exempt unincorporated business activity Engaged in a WPM ccoarrpt uninc

e Minimum Creditable Coverage (MCC) requirements for part, but not all of 2017. 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,