| Taxpayer's Name: | |
| Tax Year: | |
| Filing Status: | |
| Family Size: |
| Federal AGI: | |
| AGI of SP (if filing MFS and SP lived in household): | |
| Total AGI: |
| Offer of Employer Insurance: | |
| Lowest Monthly Premium: | |
| Citizen or Legal Resident? | |
| Denied MassHealth/Subsidized Insurance? | |
| Offer of Individual Employer Insurance? | |
| Lowest Monthly Individual Premium: | |
| County of Residence: | |
| Age (older spouse if MFJ): | |
| Insurance Plan: | |