PLEASE READ THE ATTESTATIONS BELOW AND SELECT A RESPONSE FOR EACH STATEMENT. 

To make it easier to determine my eligibility for help paying for coverage in future years, I agree to allow Marketplace to use my income date, including information from tax returns, for the next 5 years. The marketplace will send me a notice, let me make changes, and I can opt out any time

I understand that I'm not eligible for a premium tax credit if I'm found eligible for other qualifying health coverage, like Medicaid, Children's Health Insurance Program(CHIP), or a job-based health plan. I also understand that if I become eligible for other qualifying health coverage, I must contact the Marketplace to end my Marketplace coverage and premium tax credit. IF I don't, the person who files taxes in my household may need to pay back my premium tax credit.

I understand that because the premium tax credit will be paid on my behalf to reduce the cost of health coverage for myself and or my dependents , I must file a federal income tax return for the 2024 federal income tax return. If I'm married at the end of 2024, I must tile a joint income tax return with my spouse.

I also expect that: No one else will be able to claim me as a dependent on their 2024 federal income tax return. I'll claim a personal exemption deduction on my 2024 federal income tax retrun for any individual listed on the application as my dependent who is enrolled in coverage through this Marketplace, and whose premium for coverage is paid in whole or in part by advance payments of the premium tax credit.

If any of the above changes: I understand that it may impact my ability to get the premium tax credit. I also understand that when I file my 2024 federal income tax return, the Internal Revenue Service (IRS) will compare the income on my tax return with the income on my application. I understand that if the income on my tax return is lower than the amount of income on my application, I may be eligible to get additional premium tax credit amount. On the other hand, If the income on my tax return is higher than the amount of income on my application, I may owe additional federal income tax.

I know that I must tell the program I'll be enrolled in if the information I listed on the application changes. I know I can make changes in my Markeplace account or by calling the Marketplace Call Center at 1-800-318-2596 ( TTY:1-855-889-4325). I know a change in my information could affect eligibility for members of my household.

If anyone on your application is enrolled in Marketplace coverage and is later found to have other qualifying health coverage (like Medicare, Medicaid, or Children's Health Insurance Program (CHIP), the Marketplace will automatically end their Marketplace plan coverage. This will help make sure that anyone who's found to have other qualifying coverage won't stay enrolled in Marketplace coverage and have to pay full cost.

The Agent that assisted my with my application has verified all of my information on the application to be accurate and complete.

I am signing this application under penalty of perjury, which means I've provided true answers to all the questions to the best of my knowledge. I know I may be subject to penalties under federal law if I intentionally provide false information.