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Individual

NAME:
EMAIL:
Phone
SSN:(Upload a copy of social security card below)
DOB:
ADDRESS:
CITY:
STATE:
ZIP:
OCCUPATION:
ROUTING #
Checking #
DL/ID (Upload a copy of drivers license below)
Date Issued
Expiry Date
Filing Status
DEPENDENTS
DO YOU HAVE HEALTHCARE INSURANCE MARKETPLACE (ACA/OBAMACARE)?
SUBMIT FORM 1095-A
Maximum file size: 2 GB
IF YOU DON’T HAVE THE REQUIRED FORM, CALL 1-800-318-2596.
ASK FOR LINES 33 COLUMNS A, B AND C ANNUAL TOTALS.
DO YOU CURRENTLY OWE THE IRS, OWE ANY BACK CHILD SUPPORT, OR WAS DISALLOW EARNED INCOME CREDIT WITHIN THE PAST 3 YEARS?
ARE YOU IN DEFAULT ON ANY STUDENT LOANS?
HAVE YOU FILED FOR BANKRUPTCY WITHIN THE PAST 3 YEARS?

Upload Files

Your Social Security Card
Maximum file size: 5 MB
Only 1 file
Dependents Social Security Cards
Maximum file size: 5 MB
You can upload multiple files
Drivers’ License
Maximum file size: 5 MB
Only 1 file
Upload Other Documents
Maximum file size: 5 MB
You can upload multiple documents