Health Care Renewal Notice Page 11
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46Nov 24, 2014 6:07 PM
Reference Number : 10168067
2 -of- 8
Information Summary
This is the information we have about your household. We used this information to renew your coverage. You must tell us
if any of the information is not correct, including the address listed on this notice. You do not need to do anything if all of
this information is correct.
Household Information
Name
Gender
Date of Birth
Pregnant
Pam Blue
Female
01/01/1984
No
Suzie Blue
Female
01/01/2004
No
Relationships
Name
Pam Blue Is the Child of Suzie Blue
Expected Tax Filing Information
Name
Expected Tax Status
Tax Relationship
Married Filing Jointly
Pam Blue
Non Filer
No
Suzie Blue
Non Filer
No
Other Health Insurance Information
Name
Has Medicare or other Has Health Insurance
Has Access to Health
Non-employer Health
through an Employer
Insurance through an
Insurance
Employer
Income Information
This is the income we have for your household. It includes your taxable income plus any nontaxable foreign earned
income, interest income and Title II Social Security Benefits. Title II Social Security Benefits include retirement, disability
and Railroad Retirement benefits. Supplemental Security Income (SSI) is not Title II income.
Name
Type of Income
Amount
Frequency
Pam Blue
Self Employment
500.00
Monthly
Deduction Information
Allowable deductions are the types of expenses that are subtracted from the "taxable income" on the front of the 1040 tax
return, like alimony paid or student loan interest. For a complete list of allowable deductions see lines 23-35 on the 1040
tax form.
Name
Type of Deduction
Amount
Frequency
Projected Annual Income
Your projected annual income is your anticipated modified adjusted gross income (MAGI) for 2015. It is the amount of
income you expect to receive in 2015 minus the deductions you can claim on the front page of the 1040 tax form.
Name
Amount
Pam Blue
7,000.00
Suzie Blue
0.00
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