| understand the State will use Social Security Numbers for those who are applying for benefits to make “yun sure households are eligible for benefits. The State uses the State Income and Eligibilty Verification System to do computer matches. The State uses the information it finds for benefit reviews and audits. The agencies that may recelve, provide or use this information include: Workforce Services, Health, Human Services, Homeland Security, Social Security, and Intemal Revenue Service. The Stete may also use information from consumer reporting agencies. The State may ask for information from ‘banks or credit unions, and other organizations or people who may have eligibility information about ‘my household. | must give the State proof that shows my household is eligible. onoercsnest23 |, (print name) have read the statements above or someone has read them to me. | understand and agree to those statements. Under penalty of perjury, | swear that the answers I give on this application are complete and correct, | am the person represented by the signature on this document. | know | may be subject ‘0 federal or state penalties if | give false or untrue information, Providing a Social Security Number and information pertaining ‘0 immigration or alien status is voluntary; however, any person who wants assistance but does not provide such information may ‘not be eligible for benefits. Fallure to provide this information will not subject the applicant to criminal charges. Signature (check one}: ClApplicant Ci Authorized Representative Date ‘Yes CINo Would you like someone to act as an authorized representative and have access to the information regarding your case? If yes, please complete Attachment D - Authorization to Disclose Medical Eligibility Information form, attached to this application. @ RENEWAL OF COVERAGE IN FUTURE YEARS To make it easier to determine my eligibility or help paying for health coverage in future years, | agree to allow the Marketplace to-use income data, including information from tax returns. | also agree to allow the Department of Workforce Services, the Department of Human Services and the Department of Health to use information from tax returns. I can opt out at any time, The Marketplace will send me a notice and let me make changes. Yes, renew my elighility automatically for the next Os years (the maximum number of years allowed), of for a shorter number of years: D4 years C3 years C2years Ot year Don't use information from tax returns to renew my coverage. @ VOTER REGISTRATION INFORMATION Yes CINo —_ If you are not registered to vote where you live now, would you like to apply to register to vote today? If you {do not check either of these boxes, we will assume you have decided not to register to vote at this time. You may fil out the pplication form in private. if you would lke help in filing out the voter registration application forrn, we will help you. The decision to seek or accept help is yours. Choosing to register or declining to register to vote will not affect the amount of benefit that you willbe provided by this agency. if you believe that someone has interfered with your right to register, your right to decline to register to vote, your right to privacy in deciding whether to register or in applying to register to vote, or your right to choose your own political party or other politcal preference, you may fle @ complaint with the Lt. Governor, State of Utah, PO Box 142220, SLC, UT 84114, @ RETURN COMPLETED FORM TO: ‘You have now completed the application. Please return this completed application form and any needed attachments to: Department of Workforce Services, PO Box 143245, SLC, UT 84114-3245, Tollfree Fax: 1-888-522-9505 11