Application For Health Coverage & Help Paying Costs Page 2

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Page 1 of 7

Please print in capital letters using black or dark blue ink only.

(

)

Fill in the circles

like this

STEP 1:

Tell us about yourself.

(We need one adult in the family to be the contact person for your application.)

1. First name

Middle name

Last name

Suffix

2. Home address (Leave blank if you don’t have one.)

3. Apartment or suite number

4. City

5. State

6. ZIP code

7. County, parish, or township

8. Mailing address (if different from home address)

9. Apartment or suite number

10. City

11. State

12. ZIP code

13. County, parish, or township

14. Daytime phone number

15. Evening phone number

.........................................................................................................

16. Do you want to get information about this application by email?

Yes

Email address:

17. What’s your preferred spoken language? What’s your preferred written language?

STEP 2:

Tell us about your family.

Who do you need to include on this application?

Complete the Step 2 pages for every person in your family and household, even if the person has health coverage already. The information in

this application helps us make sure everyone gets the best coverage they can. The amount of help or type of program you qualify for is based on

the number of people in your family and their incomes. If you don’t include someone, even if they already have health coverage, your eligibility

results could be affected.

For adults who need coverage:

Include these people even if they aren’t applying for health coverage themselves:

•

Any spouse

•

Any son or daughter under age 21 they live with, including stepchildren

•

Any other person on the same federal income tax return (including any children over age 21 who are claimed on a parent’s tax return). You

don’t need to file taxes to get health coverage.

For children under age 21 who need coverage:

Include these people even if they aren’t applying for health coverage themselves:

•

Any parent (or stepparent) they live with

•

Any sibling they live with

•

Any son or daughter they live with, including stepchildren

•

Any other person on the same federal income tax return. You don’t need to file taxes to get health coverage.

Complete Step 2 for each person in your family.

Start with yourself, then add other adults and children. If you have more than 2 people in your family, you’ll need to make a copy of the pages

and attach them.

You don’t need to provide immigration status or a Social Security Number (SSN) for family members who don’t need health coverage. We’ll keep

all the information you provide private and secure, as required by law. We’ll use personal information only to check if you’re eligible for health

coverage.

NEED HELP WITH YOUR APPLICATION?

Visit HealthCare.gov, or call us at 1-800-318-2596. Para obtener una copia de este formulario en Español, llame 1-800-318-2596. 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. TTY users should call 1-855-889-4325.