Form ENGLISH - alejandroassociatesllc.com

APPLICANT INFORMATION

Select *

Name *

Last Name *

Date of Birth *

SSN *

Phone *

Address *

City *

State *

ZIP Code *

Citizen *

What is your citizenship status? *

Certificate of Naturalization Number *It is found in the certificate issued by USCIS

USCIS Number / Alien Number *Format: A123456789

USCIS Number / Alien Number *It is on the front or back of the card (it starts with “A”)

Card Expiration Date *It appears as “Card Expires” on the Green Card

Work Permit Number (USCIS# or A-Number) *It is located at the top of the EAD card

Permit Expiration Date *“Card Expires” en el EAD

Are you currently married? *

APPLICANT INFORMATION

FAMILY & HOUSEHOLD

Full Name

Date of birth

SSN

Relacionship

Income

USD

Applying for coverage

INCOME

What is your employment status? *

Employer name *

Employer's address *

State *

Position *

Annual Income *

USD

Economic activity or type of work performed *

Estimated annual income *

USD

SPOUSE INFORMATION

Name *

Last Name *

Date of Birth *Spouse

SSN *

Phone *

SPOUSE EMPLOYMENT INFORMATION

What is your employment status? *

Employer name *

Employer's address *Spouse

Estado/Provincia *

Position *Spouse

Annual Income *Spouse

USD

Economic activity or type of work performed *Spouse

Estimated annual income *Spouse

USD

ADDITIONAL QUESTIONS

Will you file taxes this year? *

Any individuals above disabilities / mental health issues that affect their capability to work? *

Are you claiming any dependents on your tax return? *

Any individuals above pregnant? *

Is everyone applying for coverage a US born citizen? *

Anyone above recently adopted or placed in foster care? *

Did anyone above recently get married? *

Will anyone shown above lose coverage within 60 days? *

Any individuals recently released from incarceration? *

Any individuals found not eligible for Medicaid or CHIP since the beginning of the current year? *

Any individuals above need help with activities of daily living? *

Does anyone above pay alimony student loans? *

Privacy Notice Statement

Privacy Notice Statement: I hereby agree the information contained herein has been provided to the best of my knowledge. I understand that the information provided herein will be solely used by Alejandro Associates LLC to search application and determine eligibility & enrollment through Healthcare.gov/ACA/EDE and will not be disseminated to any third party without prior consent.

Applicant's signature *

Date the REGISTRATION FORM is signed by Alejandro Associates LLC