In just 14 months, Americans will be required to prove that they have federally "qualified" health insurance or face an Obamacare tax of $695 to $2,085. That is unless you are in prison, below the poverty line, or are an undocumented immigrant, according to the anti-tax group Americans for Tax Reform.

When added together, those three groups total up to one-sixth of the nation's population of 314 million: 218,929 are in federal prisons, 12 million are illegals and 42 million are below the poverty line and eligible for welfare, though some fit into all three categories, according to federal reports.

ATR highlighted the groups eligible from the mandate to get health insurance in a mock Internal Revenue Service form they developed to show the extra paperwork Americans will be required to fill out once the full Obamacare law kicks in, January 2014. It is based on testimony from the IRS given in September that said, "taxpayers will file their tax returns reporting their health insurance coverage, and/or making a payment."

Based on other IRS requirements, ATR said that Americans will have to show that they have health insurance "qualified" by the Department of Health and Human Services. They will also have to disclose if they were covered by a qualifying plan during the year and for how long. And they could be subject to penalties and interest on unpaid Obamacare taxes for periods they were not covered.

Their mock form includes groups qualifying for exemptions from the Obamacare health insurance mandate and tax. "Classes of individuals who are exempt from the mandate include but are not limited to: those serving sentences in the federal penitentiary system; those persons not legally able to work in the U.S.; welfare recipients (since they are below the poverty line); and those qualifying for an HHS-granted religious exemption," said ATR, citing section 1501 of the Affordable Care Act that also exempts many others, including native Americans.

The anti-tax group had some fun with the mock tax form, calling theirs "Form OBMA."