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Dws-Esd 61app - Application For Food Stamps, Financial Assistance, Child Care, And Medical Assistance - 2014 Page 14

Voter Registration Information

If you are not registered to vote where you live now, would you like to apply to

Yes

•

IF YOU DO NOT CHECK EITHER OF THESE BOXES, YOU WILL BE CONSIDERED TO

HAVE DECIDED NOT TO REGISTER TO VOTE AT THIS TIME.

D34314000241429

•

If you would like help in filling out the voter registration application form, we will help you. The

decision whether to seek or accept help is yours. You may fill out the application form in private.

Applying to register or declining to register to vote will not affect the amount of assistance that

you will be provided.

•

If you believe that someone has interfered with your right to register or to decline to register to

vote, your right to privacy in deciding whether to register or in applying to register to vote, or

your right to choose your own political party or other political preference, you may file a complaint with Lt. Governor,

State of Utah, 203 State Capitol Building, Salt Lake City, UT, 84114.

Medical Only

Renewal of Coverage in Future Years

To make it easier to determine my eligibility for help paying for health coverage in future years, I agree to allow the

Marketplace to use income data, including information from tax returns. I also agree to allow the Department of Workforce

Services, the Department of Human Services and the Department of Health to use information from tax returns. I can opt

out at any time. The Marketplace will send me a notice and let me make any changes.

Yes, renew my eligibility automatically for the next:

5 years (the maximum number of years allowed), or for a shorter number of years:

4 years

3 years

2 years

1 year

Do not use information from tax returns to renew my coverage.

Page 14

Dws-Esd 61app - Application For Food Stamps, Financial Assistance, Child Care, And Medical Assistance - 2014 Page 14