Annual Income Letter of Explanation

Who can use this form?

You can use this form if you applied for Marketplace coverage and got a letter from the Marketplace saying you need to submit documents to confirm your annual income, but you don't have any of the other acceptable documents listed.

Today's Date *

First Name *

Middle Name

Last Name *

Suffix

This is the person listed first on your Marketplace application.

Primary Contact Date of Birth *

Application ID

My Household Expects To Get $ *

During The Year *

Email Address *

Phone Number

We'll use this to email you a confirmation and save a copy to your customer portal.

Notes:

The annual income you enter must match the income you reported on your Marketplace or other health insurance application. If it doesn’t, update your Marketplace application.

Remember:

Enter an accurate income estimate on your Marketplace application. If you use the premium tax credit to lower your monthly premium and don’t end your Marketplace coverage, you’ll have to pay back the premium tax credit you use when you file your federal taxes. If your estimated income changes during the year, update your Marketplace application with this information right away.