Aidyl 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.

What happens next?

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.

How to mail:

Send a copy only (not the original).
Include the printed bar code page that came with your letter. If you don't have a bar code, include your printed name and the application ID on each page of your form. Your application ID is near your mailing address at the top of your letter
Mail the form to:

Health Insurance Marketplace

Attn: Coverage Processing

465 Industrial Blvd.

London, KY 40750

Get help with this form

Online: Visit HealthCare.gov/income-and-household-information/how-to-report or HealthCare.gov/income-calculator to help estimate your expected annual income.
Phone: Call 1-844-477-7500. TTY users can call 1-855-889-4325.
In-person: There may be counselors in your area who can help. Visit LocalHelp.HealthCare.gov, or call the Marketplace Call Center at 1-800-318-2596 for more information.
En Español: Llame a nuestro centro de ayuda gratis al 1-800-318-2596.
Other languages: If you need help in a language other than English, call 1-800-318-2596 and tell the customer service representative the language you need. We'll get you help at no cost to you.

1. Today's date: (mm/dd/yyyy)

MonthDayYear

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

First nameMiddle nameLast nameSuffix

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

MonthDayYear

4 Application ID number Find this number at the top of the letter you got from the Marketplace or in your Marketplace account

5. My household expects to get $*

Annual Income

During the year*

(yyyy)

My Income for:

Year (ex: 2024)

Signature*

Notes:

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.