Mintco Subsidy Eligibility Application

Name

Date of Birth

Phone

Text
YesNo

Smoker
YesNo

Current Street Address

City

County

State

Zip

Currently Employeed (If yes Name of employer)
YesNo

Offered Group coverage
YesNo

Current Wages

Additional Income

Spouse Information

Name

Date of Birth

Phone

Text
YesNo

Smoker
YesNo

Current Street Address

City

County

State

Zip

Currently Employeed (If yes Name of employer)
YesNo

Offered Group coverage
YesNo

Current Wages

Additional Income

Dependent Information

Name

Date of Birth

Name

Date of Birth

Name

Date of Birth

Citizenship Verification for All Applicats

US Citizen (If YES go to signature)
YesNo

Legal Immigrant
YesNo

Date of US Residency

Document Type

ID# for Applicant

ID# for Spouse

ID# for Dependent

Signatures

I authorize the verification of the information provided on this form as to my credit and employment. I have received a copy of this application.

Signature of Applicant

Date