Annual Income Letter of Explanation

Who can use this form? You can use this form if you applied for Marketplace coverage and got a letter from the Marketplace saying you need to submit documents to confirm your annual income, but you don't have any of the other acceptable documents listed. Visit HealthCare.gov/verify-information/documents-and-deadlines to see a list of documents you can submit.

Print this form, or download it to your computer. Fill it out using the combined income for your household. Upload or mail your completed form. Uploading is faster. How to upload: Log into your Marketplace account. Select your current application. Select "Application details," then "Upload documents." Choose "Letter of explanation" from the list of document types, and follow the instructions. Or you can just send it to your Agent 

 

2. Name of primary applicant: (This is the person listed first on your Marketplace application

3. Primary applicant's date of birth: (mm/dd/yyyy)

5. My household expects to get $

The annual income you enter must match the income you reported on your Marketplace or other health insurance application. If it doesn't, update your Marketplace application. Visit HealthCare.gov/income-and-household-information/how-to-report or HealthCare.gov/income-calculator if you need help estimating your expected annual income. Remember: It's important to enter an accurate income estimate on your Marketplace application. If the income you entered on your application is less than the income you report on your taxes at the end of the year, you may have to pay back some or all of your premium tax credit when you file your taxes. If your estimated income changes during the year, update your Marketplace application with this information right away.

You have the right to get Marketplace information in an accessible format, like large print, braille, or audio. You also have the right to file a complaint if you feel you've been discriminated against. Visit CMS.gov/about-cms/agency-information/aboutwebsite/cmsnondiscriminationnotice or call the Marketplace Call Center at 1-800-318-2596 for more information. TTY users can call 1-855-889-4325.

CMS Product No. 12171 November 2022 This product was produced at U.S. taxpayer expense. Health Insurance Marketplace is a registered service mark of the U.S. Department of Health & Human Services.