Hiputah Premium Assistance Subsidy Application
ADVERTISEMENT
1
2P.O. Box 30192
Salt Lake City, UT 84130-0192
Fax: 801-442-0382
administered by SelectHealth
HIPUtah Premium assistance Subsidy application
a. aPPlICaNT INforMaTIoN
Last Name
First
Initial
Date of Birth
/
/
Ph# (
)
Street Address
City
State
ZIP
Name and Social Security# of Head of Household
HIPUtah enrollees who have an annual income
HiPutah Premium assistance subsidy chart
below certain levels may be eligible for the
Persons in
annual income
premium assistance subsidy program. If you
family or Household*
believe your income is at or below the amounts
$34,470
1
shown on the Premium Assistance Subsidy
$46,530
2
Chart, we recommend you complete this form
$58,590
3
by answering the questions below, attach the
$70,650
4
required additional HIPUtah documentation, and
$82,710
5
submit it with this application. You could receive
up to a 25 percent discount on your premiums.
$94,770
6
$106,830
7
Note: Premium assistance will be offered only as
$118,890
8
long as funding remains available.
B. INCoMe INforMaTIoN
1. Please list the total number of exemptions claimed on your most recent tax return filed in your household
2. Please list the total number of individuals currently in your household
3. Please tell us about your yearly household income as reflected on your most recent tax return. If you are married, your
spouse lives in your household, and you did not file a joint tax return last year; complete all columns below.
a
b
c
your return
spouse’s return
total
Filed a 1040, the total household income listed on line 22
$
$
$
Filed a 1040, total Social Security income listed on line 20a
$
$
$
Filed a 1040EZ, the adjusted gross income on line 4
$
$
$
Filed a 1040A, the total household income on line 15
$
$
$
Filed a 1040A, total Social Security income listed on line 14a
$
$
$
4. Total combined household income listed above* (amount listed in Column C above) $
5. What do you believe your yearly household income will be this year? $
* Your household size is the total number of exemptions claimed on your tax return and is not related to the total number of individuals on a
23
HIPUtah policy or application.
01/01/13
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal