TAKE A STAND!

TAKE A STAND!
ACA 2024/2025 Healthcare Application

To determine if you qualify for a tax credit the Marketplace/Healthcare.gov will retriever Identifiable information to confirm your identity. All information will be held in confidence and cannot be shared with any third party or vendor. Providing this information is voluntary or mandatory under the applicable law. Please answer all questions honestly and as accurate as possible. Please print thank you.
Todays Date

MonthDayYear
Date
Full Name
Address

Address

Street Address Line 2

CityStateZip

Postal / Zip Code
DOB
County Expected Annual Income Filling for: Myself Only Name of Employer or Business Address
County
Cell
Expected Annual Income
Email
example@example.com
Myself Family
SelfEmployed or W2
Legal US Citizen
Filling for Myself Only
Name of Employer or Business
Other
Occupation
Address

Address

Street Address Line 2

CityStateZip

Postal / Zip Code
Phone
Format: (000) 000-0000.
Spouse Full Name Spouse Annual Income
Spouse Full Name
DOB
Spouse Annual Income
With Spouse
Who all do you file on your taxes
Full Name
DOB
Full Name
Full Name
DOB
DOB
Full Name
DOB
Full Name
DOB
Signature of Applicant
Tax Credit
Monthly Premium
Dental
Deductible
Vision
MOOP
Life Ins
Retire Income
Effective Date

MonthDayYear
Date
ABUNDANCE
Mrs. Joy Financial Risk Protection Specialist

Fax 770-629-5710 Email: ojoy@securelifehealth.com

Licensed in: GA, FL, NC, ME, MI
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