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2024 OBAMACARE MEMBERS INFORMATION
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	MEMBER NAME *
	BIRTH DATE *
	SS# STATUS	HAVE a SSN DO NOT HAVE a SSN
	IMMIGRATION STATUS *	US CITIZEN PERMANENT RESIDENT DOCUMENTED UNDOCUMENTED
	CONTACT INFO *
	MEMBER ADDRESS *
	EMPLOYMENT STATUS	EMPLOYED UNEMPLOYED
	EMPLOYER NAME
	EMPLOYER PHONE NUMBER
	E-MAIL *
	2024 PROJECTED INCOME *
HOUSEHOLD MEMBER INFORMATION
	NAME
	BIRTH DATE
	SS# STATUS	HAVE a SSN DO NOT HAVE a SSN
	IMMIGRATION STATUS	US CITIZEN PERMANENT RESIDENT DOCUMENTED UNDOCUMENTED
	NAME
	BIRTH DATE
	SS# STATUS	HAVE a SSN DO NOT HAVE a SSN
	IMMIGRATION STATUS	US CITIZEN PERMANENT RESIDENT DOCUMENTED UNDOCUMENTED
	NAME
	BIRTH DATE
	SS# STATUS	HAVE a SSN DO NOT HAVE a SSN
	IMMIGRATION STATUS	US CITIZEN PERMANENT RESIDENT DOCUMENTED UNDOCUMENTED
	NAME
	BIRTH DATE
	SS# STATUS	HAVE a SSN DO NOT HAVE a SSN
	IMMIGRATION STATUS	US CITIZEN PERMANENT RESIDENT DOCUMENTED UNDOCUMENTED
	NAME
	BIRTH DATE
	SS# STATUS	HAVE a SSN DO NOT HAVE a SSN
	IMMIGRATION STATUS	US CITIZEN PERMANENT RESIDENT DOCUMENTED UNDOCUMENTED
	NOTE:

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