Health Insurance Marketplace
Depertament of Health and Human Service.
465 Industrial Boulevard.
London, Kentucky 40750-0001

INCOME STATEMENT

To whom it May concern:

state by the present, that I/we work as self employee/s and it is my/our will to declare anestimated of

as a family/household annual income for

THIS IS A DOCUMENT FOR EXCLUSIVE USE BY BAEZ AGENCY LLC.

THE NON-CONSENSUAL USE OF THIS INFORMATION MAY CAUSE LEGAL ACTIONS.