MUST READ & AGREE BEFORE ENROLLING

HEALTHCARE.GOV/MARKETPLACE 

DISCLOSURE AGREEMENT

I understand that because the premium tax credit will be paid on my behalf to reduce the cost of health coverage for myself and/or my dependents:

• I must file a federal income tax return in 2022 for the tax year 2021.

• If I’m married at the end of 2021, I must file a joint income tax return with my spouse.

I Also Expect That:

No one else will be able to claim me as a dependent on their 2021 federal income tax return. I'll claim a personal exemption deduction on my 2021 federal income tax return for any individual listed on this application as a dependent who is enrolled in coverage through this Marketplace and whose premium for coverage is paid in whole or in part by advance payments. If any of the above changes, I understand that it may impact my ability to get the premium tax credit.

I also understand that when I file my 2021 federal income tax return, the Internal Revenue Service (IRS) will compare the income on my tax return with the income on my application. I understand that if the income on my tax return is lower than the amount of income on my application, I may be eligible to get an additional premium tax credit amount.

On the other hand, if the income on my tax return is higher than the amount of income on my application, I may owe additional federal income tax.

The Federal Government/Marketplace, may request certain documents from you before approving your healthcare coverage/Obamacare. Please be prepared to show one or more of the following documents:

* Letter from Current or Previous Employer/Proof of Healthcare Coverage.

* Medicare/Medicaid Denial Letter.

* Proof of Income: Check Stub or Self-Employment Ledger, Unemployment Benefits, Pensions, etc.

* Proof of Citizenship: Driver's License, State ID, Passport or Birth Certificate, Green Card, or Social Security Card.

* Release from Incarceration/Prison Letter.