2024 Marketplace Intake Form

Community Outreach 2024
At Urban Life Advancement Center (ULAC), we value our community and take pride in helping deliver essential services to individuals and families. We understand the importance of staying connected, protecting your health, and navigating financial complexities. That's why we offer a range of programs designed to support you and your loved ones.

Stay Connected with Our Free Cell Phone Program:

Through the Lifeline program, eligible individuals can receive a free cell phone and monthly service, including minutes and texts. This program helps ensure everyone can stay connected to family, friends, employers, and emergency services.

Protect Your Health with Affordable Healthcare Coverage:

We offer healthcare coverage options with premiums starting at $0 per month. Our plans provide essential health benefits, ensuring you and your family can access the care you need. 4 out of 5 people qualify for $0 Monthly Premium Healthcare Coverage via the Marketplace.

Navigate Tax Season with Confidence:

Our experienced tax advocates are here to assist you with your tax needs. We offer guidance and support to help you file accurately and maximize your return.

If you would like Healthcare Coverage, Free Cell Phone or SIM Kit via the Lifeline Program, Tax Preparation, and/or Housing Services, please request them below.

Let's get started! Please complete this intake form so we can learn more about your needs and connect you with the right resources.
Date*

MonthDayYear
Date
Community Advocate Name:
Navigator Name:

First NameLast Name
Legal Name*

PrefixFirst NameLast Name
First Name*
Last Name*
Gender*

MaleFemale
If female, are you pregnant?*

YesNo
Date of Birth*

MonthDayYear
Date of Birth*

MonthDayYear
Date
Age
Social Security Number (if NOT U.S. Citizen, enter 000-00-000): **
Picture of Identification (ID, Passport, Parolee ID etc)

Browse Files
Id must NOT of expired more than 1 year from current date Cancelof
Are you a US Citizen:*

YesNo, but i DO have my Green CardNo, and I DO NOT have my Green Card
Green Card Number:
UPLOAD COPY OF GREEN CARD BELOW
Expiration Date:
UPLOAD COPY OF GREEN CARD BELOW
Upload a picture of your Green Card here:

Browse Files

Cancelof
Are you a member of a Native American or Alaskan tribe? (UPLOAD CARD BELOW)

YesNo
Upload a picture of your Native American or Alaskan tribe here:

Browse Files

Cancelof
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing address if different:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number (Home)*
Format: (000) 000-0000.
Phone Number (Mobile)
Format: (000) 000-0000.
Email*
example@example.com
Employment/Income Status (select ALL that apply)*

In Between JobsEmployedSSIUnemploymentSelf Employed
Employer:
Employer Phone Number:
Estimated 2024 Annual Income:
Did you file taxes for: (select all that apply):*

2021202220232024Have not filed (will not disqualify you)
Do you need help with any housing issues ie Purchase, Sell, Rent, Housing, Commercial Space? (if yes, explain in other)*

YesNo
Type of housing needed:
Are you married:*

YesNo
If married is your spouse applying:

YesNoOther
If no, reason not applying:
Spouse Name:
Date of birth

MonthDayYear
Date
Employer:
Estimated 2024 Annual Income:
Do you claim any dependents on your taxes:*

YesNo

Dependent's Information

Rows	Name (First & Last)	Date of Birth	SSN:
First Dependent Name (First/Last):
Second Dependent Name (First/Last):
Third Dependent Name (First/Last):
Fourth Dependent Name (First/Last):

Do you need to sign up for healthcare coverage with a top insurance carrier? 4 out of 5 people qualify for a $0 monthly premium.*

YesNo
Are you applying for health insurance for any children or dependents?*

YesNo
If no please provide reason:
Do you need a (FREE) Cell Phone or SIM Kit via Lifeline Program?*

YesNo
How do you qualify for the Lifeline (Free Cell Phone) Programs: ( select all that apply)

MedicaidSSIFood StampsTribal MemberSchool Food Program (must list dependent below)Income
Do you need "No Money Out of Pocket" Tax Preparation Services that will help you maximize your tax refund?*

YesNo
Do you want to qualify for an up to $6000 Tax Advance that will allow you to use your tax refund to pay back your advance?*

YesNo
Do you need help with any housing services (select ALL that apply)*

Residential PurchaseResidential SellRentalRental Section 8 or Low IncomeSheltersCommercial Space - Rental/Purchase
By checking below, I understand Urban Life Advancement Center is NOT a licensed real estate brokerage and does not hold any real estate. I understand that my name and information will be shared, at no cost, with affiliates of Urban Life Advancement Center to provide these services. I understand that Urban Life Advancement Center has Community Advocates that are licensed in the field of Real Estate that will be used. I understand that there may be cost required by affiliates of Urban Life Advancement Center to provide services other than Marketplace Insurance. I understand i will NEVER be charged for the service of enrolling in marketplace insurance. I understand each service requested is provided by a separate department with in Urban Life Advancement Center and there is no stipulation to only use one (1) service. Each service used is by my choice, requested by me, the applicant.*

Yes
AUTHORIZATION FORM
I understand that all information obtain is for the purpose of obtaining services provided by representatives of Urban Life Advancement Center that have contracts with affiliate companies to provide those said services. In most cases to obtain services, an additional application with my personal information is required including my Date of Birth and Social Security Number*

Yes
I authorize a Licensed Health Insurance Agent to review and submit my health insurance enrollment application on my behalf.*

Yes
I authorize a Licensed Health Insurance Agent to access my Healthcare.gov and Medicaid accounts to make any updates/uploads as necessary and to review and advise year to year, using any and all reasonable efforts to ensure that I have made a sound decision in choosing a Marketplace plan for the year.*

Yes
I acknowledge receipt of HIPPA Privacy information at time of enrollment.*

Yes
I understand that if I am currently covered by Medicare, Medicaid, Disability or receiving Unemployment Benefits, enrolling for health insurance through the Marketplace, may affect my current benefits.*

Yes
I attest that the information I have provided is true and accurate to the best of my knowledge and that it is my responsibility to provide proof of income, citizenship, non-incarceration and any additional information required by the service providers.*

Yes
By signing this application, I provide my signature, expressly authorizing Urban Life Advancement Center, their agents or partner companies to contact me at the number and address provided with insurance quotes or to obtain additional information for such purpose, via live, prerecorded or autodialed calls, text messages, or emails for a period of 5 years, restarting each year i use services.*

Yes
I understand that my signature is not a condition of purchasing any property, goods or services and that I have the right to revoke my consent at any time.*

Yes
I authorize Urban Life Advancement Center, including its direct affiliates and subsidiaries to obtain and use the following personal information: 1) My picture – including photographic, motion picture and electronic/video 2) My voice – including sounds and video recordings 3) Copy of Driver’s License, Green Card, Visa, Naturalization Documents, Social Security Card and Birth Certificate, for the purpose of verification of Identity and Citizenship*

Yes
When you receive your insurance card, would you like assistance finding a Primary Care Physician and schedule your initial appointment?*

YesNo
Signature:*
Spouse Signature:
Date*

MonthDayYear
Date
Should be Empty:

Community Outreach 2024

AUTHORIZATION FORM