Affordable Healthcare Informative pdf

Affordable Health Care
Today's Date*

MonthDayYear
Applicant's Name*

First NameLast Name
Applicant's Date of Birth*

MonthDayYear
Applicant's Phone Number*
Applicant's Email*
example@example.com
Applicant's Social Security Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
EMPLOYMENT
Type of Employment:*
Name of Employer or Type of Self-Employment
Employer Phone Number
Income Amount
Income Frequency

WeeklyBi-WeeklyMonthlyYearly
Dependents that are filed on taxes

Most dependents under the age of 18 will remain on state health plan.
Dependent 1

PrefixFirst NameMiddle NameLast NameSuffix
Date of Birth

MonthDayYear
Gender
Dependent 2

PrefixFirst NameMiddle NameLast NameSuffix
Date of Birth

MonthDayYear
Gender
Dependent 3

PrefixFirst NameMiddle NameLast NameSuffix
Date of Birth

MonthDayYear
Gender
By clicking submit you affirm that you are authorized to submit the information included in the form. You are also authorizing Southern Senior Advisors and its employees and agents (collectively “SSA”) permission to submit your information to the Marketplace (Healthcare.gov) solely for the intention of receiving a tax credit based on your household income. Once a tax credit amount is received SSA will contact you about health insurance and if you decide to proceed with health insurance your tax credit will be applied to a healthcare plan selected by you from the Marketplace for 2023. SSA does not promise or guarantee a tax credit will be available or granted to you, nor does SSA guarantee any health insurance received from submission of this information.
Should be Empty:

Affordable Health Care

EMPLOYMENT

Dependents that are filed on taxes