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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
# SS CARD
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
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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