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STEP 2: PERSON 1
Complete tep 2 for yourself, your spouse/partner and children ho live ith you and/or anyone on your same federal income taxreturn if you le one. ee page 1 for more information about ho to include. f you don’t le a tax return, remember to still add familymembers ho live ith you.1. First name, Middle name, Last name, & uffix 2. Relationship to you?
3. Date of birth (mm/dd/yyyy)4. ex Male Female5. ocial ecurity number ()
We need this if you want health coverage and have an SSN.
Providing your can be helpful if you don’t ant health coverage toosince it can speed up the application process. we use s to chec income and other information to see ho’s eligible for help ithhealth coverage costs. f someone ants help getting an , call 1-800-772-1213 or visit
Y users should call1-800-325-0778.6.
Do you plan to file a federal income tax return NEXT YEAR?
(You can still apply for health insurance even if you don’t file a federal income tax return.)
please anser questions a–c.
sip to question c.a.
will you le jointly ith a spouse? Yes o
name of spouse:b.
will you claim any dependents on your tax return? Yes o
list name(s) of dependents:c.
will you be claimed as a dependent on someone’s tax return? Yes o
please list the name of the tax ler:o are you related to the tax ler?7.
Are you pregnant? Yes o a.
ho many babies are expected during this pregnacy?8.
Do you need health coverage?
(Even if you have insurance, there might be a program with better coverage or lower costs.)
, anser all the questions belo.
kP to the income questions on page 3.Leave the rest of this page blan. 9.Do you have a physical, mental, or emotional health condition that causes limitations in activities (lie bathing, dressing, dailychores, etc) or live in a medical facility or nursing home? Yes o10.
Are you a U.. citizen or U.. national? Yes o11.
If you aren’t a U.S. citizen or U.S. national,
do you have eligible immigration status?Yes. Fill in your document type and D number belo.a. mmigration document type b. Document D numberc. ave you lived in the U.. since 1996? Yes o d. Are you, or your spouse or parent a veteran or an active-dutymember of the U.. military? Yes o12. Do you ant help paying for medical bills from the last 3 months? Yes o13. Do you live ith at least one child under the age of 19, and are you the main person taing care of this child? Yes o14. Are you a full-time student? Yes o15. were you in foster care at age 18 or older? Yes o16.
If Hispanic/Latino, ethnicity (OPTIONAL—check all that apply.)
Mexican Mexican American Chicano/a Puerto Rican Cuban ther17.
Race (OPTIONAL—check all that apply.)
American ndian or Filipino
uamanian or Chamorro
Blac or AfricanAlasa ative
ther Pacic slander
(Start with yourself)