For Affordable Care Act/Health enrollments:

Before completing your enrollment, please review the following attestation.

I attest that no one applying for health coverage on this application is incarcerated.

I attest that no member on the enrollment application has group coverage offered to them.

I give permission to the marketplace to access my tax returns for up to 5 years to verify my income for subsidy purposes.

I agree to have my information used and retrieved from data sources for this application. I have consent for all people I’ll list on the application for their information to be retrieved and used from data sources.

However, if I revoke permission, I understand that I will be required to a complete federal application every year to confirm my income and subsidy eligibility.

I understand that should the information listed on this application for enrollment change, it is my responsibility to update the information with the federal marketplace. I understand that I can make changes by accessing my marketplace account online or by calling 1-800-318-2596. I further understand that a change in my information could affect eligibility for members of my household.

I agree to allow HealthSherpa to submit my healthcare.gov financial assistance and health insurance application on my behalf.

I understand that changes may occur to my premium based on my subsidy eligibility results. Further, I authorize HealthSherpa and any Licensed Agent affiliated with Hill Insurance Group to submit the application for enrollment and notify me of these changes via the email I provided on the application. I understand that I’m required to provide true answers and that I may be asked to provide additional information, including proof of my eligibility for a Special Enrollment Period. If I don’t qualify, I may face penalties, including the risk of losing my eligibility for coverage.

I authorize and consent that Hill Insurance Group, Jon Hill or one of its affiliated licensed agents will be my agent of record. I authorize them to submit and sign this application on my behalf, as well as update my existing marketplace application, and process my renewal applications unless I revoke this authorization. This Consent and Authorization will Remain in place unless rescinded. This permission may be rescinded at any time by emailing .

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 2024 for the tax year of 2023.

● If I'm married at the end of 2023, I must file a joint income tax return with my spouse.

I also expect that:

● I am not currently Enrolled in Medicare or any State Medicaid Program.

● No one else will be able to claim me as a dependent on their 2023 federal income tax return.

● I'll claim a personal exemption deduction on my 2023 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 a premium tax credit. I also understand that:

● When I file my 2023 federal income tax return, the Internal Revenue Service (IRS) will compare the income on my tax return with the income on my application.

● 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.

●

If the income on my tax return is higher than the amount of income on my application, I may owe additional federal income tax.

I’m signing this application under penalty of perjury, which means I’ve provided true answers to all of the questions to the best of my knowledge. I know I may be subject to penalties under Federal law if I intentional provide false information.

By signing the document or filling out the form and attesting Yes, I am affirming that I agree to all the above statements.

Contacting Us

If there are any questions regarding this attestation, you may contact us using the information below.

The Hill Insurance Group

9819 US Highway 62

Orient, Ohio 43146

[email protected]

614-585-9163