Date:

I, Mr. /Ms., am requesting help enrolling in health insurance through the Health Insurance Marketplace. I have provided information necessary to be eligible for the tax credit granted by the Health Insurance Market and thus obtain benefits of a reduced premium. I certify that I have received and understand the advice provided by:

Agents and/or Entities: Alvaro Gonzalez / Marbelis Zapata / Michelle Guedez

NPN: 1977169 / 15529733 / 19665864

I hereby give my permission to the agents and entities specified above to act as health insurance agent or broker for me and my entire household, if applicable. By consenting to this agreement, I authorize you to view and use the confidential information provided by me in writing, electronically, or by telephone only for the purposes of one or more of the following:

1. Search and/or creation of an application in the Insurance Market;

2. Complete an application for eligibility and enrollment in a Marketplace Qualified Health Plan or other government insurance affordability programs, such as Medicaid and CHIP or advance tax credits to help pay Marketplace premiums;

3. Provide ongoing account maintenance and enrollment assistance, as needed; either

4. Respond to Marketplace inquiries regarding my Marketplace application.

I understand that my consent remains in effect until I revoke it, and I may revoke or modify my consent at any time by contacting the authorized agents and entities to receive acknowledgment that consent has been rescinded.

I have reviewed all the required information for the submission of my application. Likewise, I understand that in case of changes in the data provided below or any others, I must notify my representative immediately to update my application.

Marital status:

Projected Annual Family Income:

Number of people on your tax return: Tax Year:

How many persons in coverage?

I confirm that I have NO other medical insurance, as well as that I have no offer in my job of medical coverage.

I am signing this consent under penalty of perjury, which means that I have provided true answers to all questions to the best of my knowledge. I know that I may be subject to penalties under federal law if I intentionally provide false information.