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Obamacare 2024
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FULL NAME
*
ADDRESS
*
ZIP CODE
*
PHONE NUMBER
*
EMAIL
*
DOB
*
SEX
*
Male
Female
FILE TAX AS
Single
Married
SOCIAL SECURITY NUMBER
*
NAME IN SS
IMMIGRATION STATUS
*
Resident
Citizen
Work Permit
Other Status
USCIS #
NAME ON CARD
CARD #
SINCE:
EXP:
PLACE OF EMPLOYMENT
ANNUAL REVENUE
# OF PEOPLE
DEPENDENT 1. NAME
RELATION
Spouse
Child
Parent
Other
DOB
SS NUMBER
IMMIGRATION STATUS
Resident
Citizen
Work Permit
Other Status
USCIS #
CATEGORY
CARD #
PLACE OF EMPLOYMENT
ANNUAL REVENUE
WANTS INS
HAS MEDICAID
RELATION
Spouse
Child
Parent
Other
DEPENDENT 2. NAME
DOB
SS NUMBER
IMMIGRATION STATUS
Resident
Citizen
Work Permit
Other Status
USCIS #
CATEGORY
CARD #
PLACE OF EMPLOYMENT
ANNUAL REVENUE
WANTS INS
HAS MEDICAID
DEPENDENT 3. NAME
RELATION
Spouse
Child
Parent
Other
DOB
3. REVENUE
SS NUMBER
IMMIGRATION STATUS
Resident
Citizen
Work Permit
Other Status
USCIS #
CATEGORY
CARD #
PLACE OF EMPLOYMENT
ANNUAL REVENUE
WANTS INS
HAS MEDICAID
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