What is your total projected household income for the year you’re applying for coverage (e.g., if applying for 2025 coverage, estimate your 2025 income)?

Please include all sources of income for each person in your tax household. Your tax household includes everyone you claim as a dependent on your tax return, even if they have separate insurance. Income that should be counted includes:

• Wages and salaries before taxes (include tips and bonuses)

• Self-employment income (after business deductions)

• Unemployment benefits

• Social Security benefits

• Rental or investment income

For guidance, you can refer to your most recent tax return. This amount will generally be similar to Line 11 on Form 1040 if your income is expected to be close to that amount. If you’re unsure about specific income details, please consult a CPA for assistance.

Consent

I authorize Kate Spilsbury to be my health insurance agent for myself and my household. This allows Kate Spilsbury to enroll me, or my family, in a Qualified Health Plan on the Federally Facilitated Marketplace. By agreeing to this, I give permission for Kate Spilsbury to use my confidential information for the following purposes:

1. Search for an existing Marketplace application.

2. Complete applications for eligibility and enrollment in a Marketplace plan or other government insurance programs.

3. Provide ongoing account maintenance and enrollment assistance.

4. Respond to inquiries from the Marketplace regarding my application. The Agent will keep my personal information private and secure, using it only for the purposes listed above. I confirm that the information I provide on my application will be accurate to the best of my knowledge. I understand that I am not obligated to share additional personal information beyond what is required for the application. I can revoke or modify my consent at any time by emailing info@merebenefits.com

   I authorize you to enroll me in the best available plan. I grant you access to my healthcare.gov account for submitting necessary information. By signing below, I confirm my understanding and agreement to the terms outlined in this attestation.

Agent of Record: Kate Spilsbury

NPN: 9527400

Phone Number: (904) 654-5450

Email Address: info@merebenefits.com