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OBAMACARE/HEALTHCARE REFORM
PRE QUALIFICATION FORM

Step 1

Tell us about yourself.

Do you want to get infromation about this application by email?

Date of Birth
Sex

Spouse Date of birth
Spouse Sex

Are you a U.S citizen or U.S national?
Is you spouse a U.S citizen or U.S national?

If you aren't a U.S. citizen or U.S. national, do you have eligile immigration status?

If your spouse isn't a U.S. citizen or U.S. national, do you have eligile immigration status?

Are you or your spouse pregnant?

Race (OPTIONAL - check all that apply.)

Step 2

Current job & income information

If you or your spouse currently employed tell us you income. Start with QuestionYou

If you or your spouse currently employed tell us you income. Start with QuestionSpouse

CURRENT JOB:

Wages/tips (before taxes)

SPOUSE CURRENT JOB:

Wages/tips (before taxes)

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.

Step 3

Dependant(s) Information

1. Dependant Details

2. Dependant Details

3. Dependant Details

4. Dependant Details

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)

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