Health Care Renewal Notice Page 19
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46Nov 24, 2014 7:35 PM
Reference Number : 10166532
2 -of- 9
Renewal Form
This is the information we have about your household. You must review the information on this form, including the
address listed on this notice, and tell us if any of the information is not correct. Send the signed form to the servicing
agency listed on the top of this notice. You must return the form within 30 days. Call your worker or the DHS Member
Help Desk at 651-431-2670 or 1-800-657-3739 if you have questions.
Household Information
Name
Gender
Date of Birth
Pregnant
Thomas Orange
Male
01/01/1984
No
All of this information is correct unless a change is entered below:
_____________________________________________________
We will need more information if you need to add a new person to your household. Call your worker or the DHS Member Help Desk at
651-431-2670 or 1-800-657-3739.
Relationships
Name
All of this information is correct unless a change is entered below:
_____________________________________________________
Expected Tax Filing Information
Name
Expected Tax Status
Tax Relationship
Married Filing Jointly
Thomas Orange
Tax Filer
No
All of this information is correct unless a change is entered below:
_____________________________________________________
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
All of this information is correct unless a change is entered below:
_____________________________________________________
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
Thomas Orange
Wages before taxes at XYZ
729.37
Semi Monthly
Corporation
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