EmailMe Form - Affordable Care Act Form

Name *
First Last
Email *
Best phone to call you *
### - ### - ####
Secondary phone
### - ### - ####
Date of birth *
MM / DD / YYYY
Spouse
First Last
Date of birth
MM / DD / YYYY
Residence Zip code *
US Citizenship *
Yes
No
If not... Resident Card #
If employed, Name of Employer
How many dependents to cover?
Projcted Taxable Income for 2015 *
If married, do you file jointly? *
Anyone paying student loan or alimony? *
Seeking Tax Credit?
Have you previously registered?

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