We are authorized to collect the information on this form and any supporting documentation, including social security numbers, under the Patient Protection and Affordable Care Act (Public Law No. 111-148), as amended by the Health Care and Education Reconciliation Act of 2010 (Public Law No. 111-152), and the Social Security Act. While providing the requested information (including social security numbers) is voluntary, failing to provide it may delay or prevent your ability to obtain health coverage through the Marketplace, advance payment of the premium tax credits, cost sharing reductions, or an exemption from the shared responsibility payment. If you don’t provide correct information on this form or knowingly and willfully provide false or fraudulent information, you may be subject to a penalty and other law enforcement action.
Bank Account.
Credit / Debit card.
Please add any dependent who is in your taxes, in the current year, even if it is not applying for coverage.
By signing this form, you confirm that the information given is true; If there is any change in your family unit, your income or any situation that impacts your upcoming taxes, it is MANDATORY to keep the application updated, therefore, it is your responsibility to inform us.
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