OBAMACARE/HEALTHCARE REFORM PRE QUALIFICATION FORM Step 1 Tell us about yourself. Do you want to get infromation about this application by email? YesNo Date of Birth Sex MaleFemale Spouse Date of birth Spouse Sex MaleFemale Are you a U.S citizen or U.S national? YesNo Is you spouse a U.S citizen or U.S national? YesNo If you aren't a U.S. citizen or U.S. national, do you have eligile immigration status? Yes, Fill in your document type and ID number below. If your spouse isn't a U.S. citizen or U.S. national, do you have eligile immigration status? Yes, Fill in your document type and ID number below. Are you or your spouse pregnant? YesNo Race (OPTIONAL - check all that apply.) WhiteAmerican Indian or Alaska NativeFlipnioVietnameseGuamanian or ChamorroBlack of African AmericanAsian IndianKoreanNative HawalianOther Pacific IslanderChineseOther Step 2 Current job & income information If you or your spouse currently employed tell us you income. Start with QuestionYouEmployedNot Employed - Skip to question 11.Self Employed - Skip to question 10. If you or your spouse currently employed tell us you income. Start with QuestionSpouseEmployedNot Employed - Skip to question 11.Self Employed - Skip to question 10. CURRENT JOB: Wages/tips (before taxes) HourlyWeeklyEvery 2 weeksTwice a monthMontylyYearly SPOUSE CURRENT JOB: Wages/tips (before taxes) HourlyWeeklyEvery 2 weeksTwice a monthMontylyYearly If self-employed, answer the following questions: How much net income (profits once business expanses are paid) If your spouse is self-employed, answer the following questions: How much net income (profits once business expanses are paid) OTHER INCMOME THIS MONTH: Check all that apply, and give the amount and how often you get it. Check all that apply, and give the amount and how often you get it.None Unemployment Pensions Social Security Retirement accounts Alimony received Net farming/fishing Other Income Step 3 Dependant(s) Information 1. Dependant Details US Citizen Resident# TPS# MaleFemale 2. Dependant Details US Citizen Resident# TPS# MaleFemale 3. Dependant Details US Citizen Resident# TPS# MaleFemale 4. Dependant Details US Citizen Resident# TPS# MaleFemale Read & sign this application. I'm signing this application under penalty of perjury, which means i've provided true answers to all questions on this form to teh best of my knowledge. I know that I may be subject to penalties under federal law if I intentionally provide false or untrue Information. I know that I must tell the Time Financial Insurance if anything changes (and is different than) what I wrote on this application. I understand that a change in my information could affect my eligibility. I know that under federal law, discrimination isn't permitted on the basis of race, color, national origin, sex, age, sexual orientation, gender identity, or disability. I can file complaint of discrimination by visiting www.hhs.gov/ocr/office/file I confirm that i'm not offered health coverage from a employer. I confirm that next year I expect to file a federal income tax return, won't claim dependents on that return, and can't be claimed as a dependent on anyone else's federal income tax return Signature Date (mm/dd/yyyy)
