Before completing your enrollment, please review the following attestation and sign below.

I attest hat no one applying for health coverage on this application is incarcerated. I attest that no member on the enrollment application has group coverage offered to them. I give permission to the marketplace to access my tax returns for up to 5 years to verify my income for subsidy purposes. This permission can be revoked at any time. However, if I revoke permission, I understand that I will be required to complete a federal application every year to confirm my income and subsidy eligibility.

I understand that should the information listed on this application for enrollment change, it is my responsibility to update the information with the federal marketplace. I understand that I can make changes by accessing my marketplace account online.

I further understand that a change in my information could affect eligibility for members of my household. I agree to allow Amerus Financial Group to submit my healthcare.gov financial assistance and health insurance application on my behalf. I understand that changes may occur to my premium based on my subsidy eligibility results. Further, I authorize Benefit Align and Amerus Financial Group to submit the application for enrollment and notify me of these changes via the email I provided on the application. I acknowledge as my agent of record and authorize them to submit and sign this application on my behalf.

I understand that because the premium tax credit will be paid on my half to reduce the cost of health coverage for myself and/or my dependents

• I must file a federal income tax return in 2022 for the tax year of 2022
• If I'm married at the end of 2022, I must file a joint income tax return with my spouse

I also except that:

• No one else will be able to claim me as a dependent on their 2022 federal income tax return.
• I'll claim a personal exemption deduction on my 2022 federal income tax return for any individual listed on this application as a dependent who is enrolled in coverage through this marketplace and whose premium coverage is paid in whole or in part by advance payments
• if any of the above changes, I understand that it may impact my ability to get a premium tax credit

I also understand that:

• When I file my 2022 federal income tax return, the Internal Revenue Service (IRS) will compare the income on my tax return with the income on my application.
• If the income on my tax return is lower than the amount of income on my application I may be eligible to get additional premium tax credit amount.
• If the income on my tax return is higher than the amount of income on my application, I may owe additional federal income tax.

By signing below, I am affirming that I agree to all the above statements and have received a copy of the privacy statement.

The transaction will appear on your bank statement as "NBBA" or "Business Benefit Alliance"