Annual Income Letter of Explanation

Annual Income Letter of Explanation
Date*

MonthDayYear
Date
Legal Name of Primary Applicant*

First NameMiddle NameLast NameSuffix
Primary Applicant Date of Birth*

MonthDayYear
Date
Application ID*
My household expects to get:*
Annual Income
During the Year*
Remember: It’s important to enter an accurate income estimate on your health insurance 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.