Application For Health Coverage & Help Paying Costs Page 4

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Page 3 of 7

STEP 2: PERSON 1

(Continue with yourself.)

Current job & income information

Employed: If you’re currently employed, tell us

Not employed:

Self-employed:

about your income. Start with question 21.

Skip to question 31.

Skip to question 30.

Current job 1:

21. Employer name

a. Employer address

b. City

c. State

d. ZIP code

22. Employer phone number

23. Wages/tips (before taxes)

24. Average hours worked each WEEK

Hourly

Weekly

Every 2 weeks

Twice a month

Monthly

Yearly

Current job 2:

(If you have additional jobs and need more space, attach another sheet of paper.)

25. Employer name

a. Employer address

b. City

c. State

d. ZIP code

26. Employer phone number

27. Wages/tips (before taxes)

28. Average hours worked each WEEK

Hourly

Weekly

Every 2 weeks

Twice a month

Monthly

Yearly

29. In the past year, did you:

Change jobs

Stop working

Start working fewer hours

None of these

30. If self-employed, answer a and b:

a. Type of work:

b. How much net income (profits once business expenses are paid) will you get from this

self-employment this month? See instructions.

31.

Other income you get this month:

Fill in all that apply, and give the amount and how often you get it. Fill in here if none.

NOTE: You don’t need to tell us about income from child support, veteran’s payments, or Supplemental Security Income (SSI).

How often?

Unemployment

Alimony received

Pension

How often?

Net farming/fishing

How often?

Social Security

Net rental/royalty

Retirement

Other income

How often?

accounts

Type:

Deductions:

32.

Fill in all that apply, and give the amount and how often you pay it. If you pay for certain things that can be deducted on a federal income

tax return, telling us about them could make the cost of health coverage a little lower.

NOTE: You shouldn’t include child support that you pay, or a cost already considered in your answer to net self-employment (question 30b).

Other deductions

Alimony paid

How often?

Type:

Student loan

How often?

interest

33. Complete this question if your income changes during the year, like if you only work at a job for part of the year or receive a benefit for certain

months. If you don’t expect changes to your monthly income, skip to the next person.

Your total income this year

Your total income next year (if you think it will be different)

Thanks! This is all we need to know about you.

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.