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Initial here:Page 4 of 7STEP 2: PERSON 2If you have more than two people to include, make a copy ofStep 2: Person 2 (pages 4 and 5) and complete.Complete Step 2 for yourself, your spouse/partner and children who live with you, and/or anyone on your same federal incometax return if you file one. Include anyone on your tax return or who you live with, even if they do not live with you or are notapplying for health coverage. If you don’t file a tax return, remember to still add family members who live with you.1. First nameMiddle nameLast name2. Relationship to you? (See instructions.)3. Date of birth (mm/dd/yyyy)/-5. Social Security number (SSN)Suffix/YesMaleFemaleWe need this if you want health coverage for PERSON 2and PERSON 2 has an SSN.-6. Does PERSON 2 live at the same address as you?4. SexNoIf no, list address:7. Does PERSON 2 plan to file a federal income tax return NEXT YEAR?(You can still apply for health insurance even if PERSON 2 doesn’t file a federal income tax return.)YES. If yes, please answer questions a–c.NO. If no, skip to question c.Yesa. Will PERSON 2 file jointly with a spouse?NoIf yes, name of spouse:b. Will PERSON 2 claim any dependents on your tax return?YesNoIf yes, list name(s) of dependents:c. Will PERSON 2 be claimed as a dependent on someone’s tax return?YesNoIf yes, please list the name of the tax filer:How is PERSON 2 related to the tax filer?8. Is PERSON 2 pregnant?YesNo a. If yes, how many babies are expected during this pregnancy?9. Does PERSON 2 need health coverage?(Even if PERSON 2 has insurance, there might be a program with better coverage or lower costs.)YES. If yes, answer all the questions below.NO. If no, SKIP to the income questions on page 5.Leave the rest of this page blank.10. Does PERSON 2 have a physical, mental, or emotional health condition that causes limitations in activities (like bathing, dressing, dailychores, etc.) or live in a medical facility or nursing home?YesNo11. Is PERSON 2 a U.S. citizen or U.S. national?YesNo12. If PERSON 2 isn’t a U.S. citizen or U.S. national, do they have eligible immigration status? (See instructions.)Yes. Fill in PERSON 2’s document type and ID number below.a. Immigration document type:b. Document ID numberc. Has PERSON 2 lived in the U.S. since 1996?YesNod. Is PERSON 2, or PERSON 2’s spouse or parent, a veteran or anactive-duty member of the U.S. military?YesNo13. Does PERSON 2 want help paying for 14. Does PERSON 2 live with at least one child under the age of 19,medical bills from the last 3 months?and is PERSON 2 the main person taking care of this child?YesNoYes15. Was PERSON 2 in fostercare at age 18 or older?NoYesNoPlease answer the following questions if PERSON 2 is 22 or younger:16. Did PERSON 2 have insurance through a job and lose it within the past 3 months?a. If yes, end date:YesNob. Reason the insurance ended:17. Is PERSON 2 a full-time student?YesNo18. If Hispanic/Latino, ethnicity (OPTIONAL—check all that apply.)Mexican AmericanChicano/aMexican19. Race (OPTIONAL—check all that apply.)WhiteBlack or AfricanAmericanPuerto RicanAmerican Indian or AlaskaNativeAsian ameseOther AsianNative HawaiianGuamanian or ChamorroSamoanOther Pacific IslanderOtherNow, tell us about any income from PERSON 2 on the back.NEED HELP WITH YOUR APPLICATION? Visit DCHealthLink.com or call us at 1-855-532-5465. Para obtener una copia de este formularioen Español, llame 1-855-532-5465. If you need help in a language other than English, call 1-855-532-5465 and tell the customer servicerepresentative the language you need. We’ll get you help at no cost to you. TTY users should call 711.

Initial here:Page 5 of 7STEP 2: PERSON 2Current job & income informationEmployed: If PERSON 2 is currently employed, tell usabout his or her income. Start with question 20.Not employed: Skip to question 30.Self-employed: Skip to question 29.CURRENT JOB 1:20. Employer namea. Employer addressb. Cityc. State22. Wages/tips (before taxes) d. ZIP codeHourlyWeeklyEvery 2 weeksTwice a monthMonthlyYearly21. Employer phone number()–23. Average hours worked each WEEKCURRENT JOB 2: (If PERSON 2 has more jobs, attach another sheet of paper.)24. Employer namea. Employer addressb. Cityc. State26. Wages/tips (before taxes) d. ZIP codeHourlyWeeklyEvery 2 weeksTwice a monthMonthlyYearly28. In the past year, did PERSON 2:Change jobsStop working25. Employer phone number()–27. Average hours worked each WEEKStart working fewer hoursNone of these29. If PERSON 2 is self-employed, answer the following questions:a. Type of work:b. How much net income (profits once business expenses are paid) will PERSON 2get from this self-employment this month? (See instructions.)30. OTHER INCOME THIS MONTH: Check all that apply, and give the amount and how often PERSON 2 gets it. Check here if none.NOTE: You don’t need to tell us about PERSON 2’s child support, veteran’s payment, or Supplemental Security Income (SSI).Unemployment How often?Alimony received How often?Pension How often?Net farming/fishing How often?Social Security How often?Net rental/royalty How often?Retirementaccounts How often?Other incomeType: How often?31. DEDUCTIONS: Check all that apply, and give the amount and how often PERSON 2 gets it. If PERSON 2 pays for certain things that can bededucted on a federal income tax return, telling us about them could make the cost of health coverage a little lower.NOTE: You shouldn’t include a cost that you already considered in your answer to net self-employment (question 29b).Alimony paid How often?Student loaninterest How often?Other deductionsType: 32. YEARLY INCOME: Complete only if PERSON 2’s income changes from month to month.If you don’t expect changes to PERSON 2’s monthly income, skip to the next person.PERSON 2’s total income this year PERSON 2’s total income next year (if you think it will be different) How often?THANKS!This is all we need to knowabout PERSON 2.NEED HELP WITH YOUR APPLICATION? Visit DCHealthLink.com or call us at 1-855-532-5465. Para obtener una copia de este formularioen Español, llame 1-855-532-5465. If you need help in a language other than English, call 1-855-532-5465 and tell the customer servicerepresentative the language you need. We’ll get you help at no cost to you. TTY users should call 711.

Initial here:Page 6 of 7STEP 3American Indian or Alaska Native (AI/AN) family member(s)1. Are you or is anyone in your family American Indian or Alaska Native?NO. If no, skip to Step 4.YES. If yes, go to Appendix B.STEP 4Your family’s health coverageAnswer these questions for anyone who needs health coverage.1. Is anyone enrolled in health coverage now from the following?YES. If yes, check the type of coverage and write the person(s)’ name(s) next to the coverage they have.MedicaidEmployer insuranceCHIPName of health insurance:NO.Policy number:MedicareTRICARE (Don’t check if you have Direct Care or Line of Duty)VA health care programPeace CorpsIs this COBRA coverage?YesIs this a retiree health plan?NoYesNoOtherName of health insurance:Policy number:Is this a limited-benefit plan (like a school accident policy)?YesNo2. Is anyone listed on this application offered health coverage from a job?Check yes even if the coverage is from someone else’s job, such as a parent or spouse.YES. If yes, you’ll need to complete and include Appendix A. Is this a state employee benefit plan?YesNoNO. If no, continue to Step 5.STEP 5Read & sign this application. I’m signing this application under penalty of perjury, which means I’ve provided true answers to all the questions on this formto the best of my knowledge. I know that I may be subject to penalties under federal law if I intentionally provide false oruntrue information. I know that I must tell DC Health Link if anything changes (and is different than) what I wrote on thisapplication. I can visit DCHealthLink.com or call 1-855-532-5465 to report any changes. I understand that a changein my information could affect the eligibility for member(s) of my household. I know that under federal law, discrimination isn’t permitted on the basis of race, color, national origin, sex, age, sexualorientation, gender identity, or disability. I can file a complaint of discrimination by visiting www.hhs.gov/ocr/office/file. I know that my information on this form will be used only to determine eligibility for health coverage and will be kept privateas required by law. I confirm that no one applying for health insurance on this application is incarcerated (detained or jailed). If not,is incarcerated.(name of person)We need this information to check your eligibility for help paying for health coverage if you choose to apply. We’ll check youranswers using information in our electronic databases and databases from the Internal Revenue Service (IRS), Social Security, theDepartment of Homeland Security, and/or a consumer reporting agency. If the information doesn’t match, we may ask you tosend us proof.NEED HELP WITH YOUR APPLICATION? Visit DCHealthLink.com or call us at 1-855-532-5465. Para obtener una copia de este formularioen Español, llame 1-855-532-5465. If you need help in a language other than English, call 1-855-532-5465 and tell the customer servicerepresentative the language you need. We’ll get you help at no cost to you. TTY users should call 711.

Initial here:Page 7 of 7STEP 5(Continued)Renewal of coverage in future yearsTo make it easier to determine my eligibility for help paying for health coverage in future years, I agree to allow DC Health Linkto use income data, including information from tax returns. DC Health Link will send me a notice and let me make any changes,and I can opt out at any time.Yes, renew my eligibility automatically for the next5 years (the maximum number of years allowed), or for a shorter number of years:4 years3 years2 years1 yearDon’t use information from tax returns to renew my coverage.If anyone on this application is eligible for Medicaid I’m giving to the Medicaid agency our rights to pursue and get any money from other health insurance, legal settlements, orother third parties. I’m also giving to the Medicaid agency rights to pursue and get medical support from a spouse or parent. Does any child on this application have a parent living outside of the home? If yes, I know I’ll be asked to cooperate with the agency that collects medical support from an absent parent. If I think thatcooperating to collect medical support will harm me or my children, I can tell Medicaid and I may not have to cooperate.YesNoWhat should I do if I think my eligibility results are wrong?If you don’t agree with what you qualify for, in many cases, you can ask for an appeal. Please review your eligibility notice to findappeals instructions specific to each person in your household, including how many days you have to request an appeal. Belowis important information to consider when requesting an appeal: You can have someone request or participate in your appeal if you want to. That person can be a friend, relative, lawyer, orother individual. Or, you can request and participate in your appeal on your own. If you request an appeal, you may be able to keep your eligibility for coverage while your appeal is pending. The outcome of an appeal could change the eligibility of other members of your household.Sign this application. The person who filled out Step 1 should sign this application. If you’re an authorized representative, youmay sign here as long as you’ve provided the information required in Appendix C.SignatureDate (mm/dd/yyyy)/STEP 6/Mail completed application.Mail your signed application to:DC Health LinkDepartment of Human ServicesCase Records Management UnitP.O. Box 91560Washington DC 20090If you want to register to vote, you can complete a voter registration form at DCBOEE.org.PRA Disclosure StatementAccording to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB controlnumber. The valid OMB control number for this information collection is 0938-1191. The time required to complete this information collection is estimated toaverage 45 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and reviewthe information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to:CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.NEED HELP WITH YOUR APPLICATION? Visit DCHealthLink.com or call us at 1-855-532-5465. Para obtener una copia de este formularioen Español, llame 1-855-532-5465. If you need help in a language other than English, call 1-855-532-5465 and tell the customer servicerepresentative the language you need. We’ll get you help at no cost to you. TTY users should call 711.

APPENDIX AForm ApprovedOMB No. 0938-1191Health Coverage from JobsYou DON’T need to answer these questions unless someone in the household is eligible for health coverage from a job. Attach acopy of this page for each job that offers coverage.Tell us about the job that offers coverage.Take the Employer Coverage Tool on the next page to the employer who offers coverage to help you answer these questions.You only need to include this page when you send in your application, not the Employer Coverage Tool.Employee information1. Employee name (First, Middle, Last)2. Employee Social Security number--Employer information3. Employer name4. Employer Identification Number (EIN)5. Employer address6. Employer phone number(7. City)8. State–9. ZIP code10. Who can we contact about employee health coverage at this job?11. Phone number (if different from above)()12. Email address–13. Are you currently eligible for coverage offered by this employer, or will you become eligible in the next 3 months?Yes (Continue)13a. If you’re in a waiting or probationary period, when can you enroll in coverage? (mm/dd/yyyy)//List the names of anyone else who is eligible for coverage from this job.Name:Name:Name:No (Stop here and go to Step 5 in the application)Tell us about the health plan offered by this employer.14. Does the employer offer a health plan that meets the minimum value standard*?YesNo15. For the lowest-cost plan that meets the minimum value standard* offered only to the employee (don’t include family plans):If the employer has wellness programs, provide the premium that the employee would pay if he/ she received the maximum discount forany tobacco cessation programs, and did not receive any other discounts based on wellness programs.a. How much would the employee have to pay in premiums for this plan?b. How often?WeeklyEvery 2 weeksTwice a month Once a month QuarterlyYearly16. What change will the employer make for the new plan year (if known)?Employer won’t offer health coverage Employer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to theemployee that meets the minimum value standard.* (Premium should reflect the discount for wellness programs. See question 15.)a. How much will the employee have to pay in premiums for that plan?b. How often?WeeklyEvery 2 weeksc. Date of change (mm/dd/yyyy):/Twice a month Once a month QuarterlyYearly/*An employer-sponsored health plan meets the “minimum value standard” if the plan’s share of the total allowed benefit costs covered by the plan is no less than60 percent of such costs (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986).NEED HELP WITH YOUR APPLICATION? Visit DCHealthLink.com or call us at 1-855-532-5465. Para obtener una copia de este formularioen Español, llame 1-855-532-5465. If you need help in a language other than English, call 1-855-532-5465 and tell the customer servicerepresentative the language you need. We’ll get you help at no cost to you. TTY users should call 711.

EMPLOYER COVERAGE TOOLForm ApprovedOMB No. 0938-1191Use this tool to help answer questions in your DC Health Link application, Appendix A. That part of the application asks about any employerhealth coverage that you’re eligible for (even if it’s from another person’s job, like a parent or a spouse). The information in the numbered boxesbelow match the boxes in Appendix A. For example, you can use the answer to question 14 on this page to answer question 14 on Appendix A.Write your name and Social Security number in boxes 1 and 2 and ask the employer to fill out the rest of the form. Complete one toolfor each employer that offers health coverage that you’re eligible for.EMPLOYEE informationThe employee needs to fill out this section.1. Employee name (First, Middle, Last)2. Employee Social Security Number--EMPLOYER informationAsk the employer for this information.3. Employer name4. Employer Identification Number (EIN)5. Employer address (the Marketplace will send notices to this address)6. Employer phone number(7. City)8. State–9. ZIP code10. Who can we contact about employee health coverage at this job?11. Phone number (if different from above)()12. Email address–13. Is the employee currently eligible for coverage offered by this employer, or will the employee be eligible in the next 3 months?Yes (Go to question 13a.)13a. If the employee is not eligible today, including as a result of a waiting or probationary period, when is the employee eligible forcoverage?(mm/dd/yyyy) (Go to next question)No (STOP and return this form to employee)Tell us about the health plan offered by this employer.Does the employer offer a health plan that covers an employee’s spouse or dependent?Yes. Which people?SpouseDependent(s)No(Go to question 14)14. Does the employer offer a health plan that meets the minimum value standard*?Yes (Go to question 15)No (STOP and return this form to employee)15. For the lowest-cost plan that meets the minimum value standard* offered only to the employee (don’t include family plans): If theemployer has wellness programs, provide the premium that the employee would pay if he/she received the maximum discount for anytobacco cessation programs, and didn’t receive any other discounts based on wellness programs.a. How much would the employee have to pay in premiums for this plan? b. How often?WeeklyEvery 2 weeksTwice a monthOnce a monthQuarterlyYearly (Go to next question)If the plan year will end soon and you know that the health plans offered will change, go to question 16. If you don’t know, STOP and returnthis form to employee.16. What change will the employer make for the new plan year?Employer won’t offer health coverageE mployer will start offering health coverage to employees or change the premium for the lowest-cost plan that meets the minimumvalue standard* and is available to the employee only. (Premium should reflect the discount for wellness programs. See question 15.)a. How much will the employee have to pay in premiums for that plan? b. How often?WeeklyEvery 2 weeksc. Date of change (mm/dd/yyyy):/Twice a monthOnce a monthQuarterlyYearly/*An employer-sponsored health plan meets the “minimum value standard” if the plan’s share of the total allowed benefit costs covered by the plan is no les

N H WITH O ITION Visit DCHealthLink.com or call us at 1-855-532-5465.Para obtener una copia de este formulario en Español, llame 1-855-532-5465.If you need help in a language other than English, call 1-855-532-5465 and tell the customer service representative the language you need.