Application For Health Coverage & Help Paying Costs Page 6

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Tell us about any income PERSON 2 gets.

STEP 2: PERSON 2

Complete this page even if PERSON 2 doesn’t need health coverage.

Current job & income information

Employed: If PERSON 2 is currently employed,

Not employed:

Self-employed:

tell us about his/her income. Start with question 23.

Skip to question 33.

Skip to question 32.

Current job 1:

23. Employer name

a. Employer address

b. City

c. State

d. ZIP code

24. Employer phone number

25. Wages/tips (before taxes)

26. Average hours worked each WEEK

Hourly

Weekly

Every 2 weeks

Twice a month

Monthly

Yearly

Current job 2:

(If PERSON 2 has more jobs, attach another sheet of paper.)

27. Employer name

a. Employer address

b. City

c. State

d. ZIP code

28. Employer phone number

29. Wages/tips (before taxes)

30. Average hours worked each WEEK

Hourly

Weekly

Every 2 weeks

Twice a month

Monthly

Yearly

31. In the past year, did PERSON 2:

Change jobs

Stop working

Start working fewer hours

None of these

32. If PERSON 2 is self-employed, answer the following questions:

a. Type of work:

b. How much net income (profits once business expenses are paid) will PERSON 2 get from this

self-employment this month? See instructions.

Other income PERSON 2 gets this month:

33.

Fill in all that apply, and give the amount and how often PERSON 2 gets it. Fill in here if none.

NOTE: You don’t need to tell us about PERSON 2’s 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:

34.

Deductions:

Fill in all that apply, and give the amount and how often PERSON 2 gets it. If PERSON 2 pays 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 PERSON 2 pays, or a cost already considered in the answer to net self-employment (question 32b).

Other deductions

How often?

Alimony paid

How often?

Type:

Student loan

How often?

interest

35. Complete only if PERSON 2’s income changes during the year, like if PERSON 2 only works at a job for part of the year or receives a

benefit for certain months. If you don’t expect changes to PERSON 2’s monthly income, skip to the next person.

PERSON 2’s total income this year

PERSON 2’s total income next year

Thanks! This is all we need to know about PERSON 2.

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.