Enter Tax Dependent's information below
Enter Tax Dependent's Information Below
Enter Tax Dependents Information Below
I hereby acknowledge my agreement to the contents of this attestation. By affixing my signature below, I respectfully request this agent or its agency affiliates to enroll both myself and/or my family in the most optimal $0 ACA plan. Additionally, I authorize them to access my healthcare.gov account and submit the necessary information in accordance with the details provided.
