Document text
Letter of Explanation: Household Income
[FULL NAME]
[ADDRESS]
[PHONE] · [EMAIL]
[DATE]
Health Insurance Marketplace
Attn: Coverage Processing
465 Industrial Blvd.
London, KY 40750
Re: Income for [YEAR] · Application ID [APPLICATION ID]
To the Marketplace:
I received your letter dated [DATE OF YOUR LETTER] asking me to confirm my household income.
My household expects to get $[ANNUAL INCOME] in [YEAR].
This amount differs from your records because [WHAT CHANGED, FOR EXAMPLE: I CHANGED JOBS ON A DATE, MY HOURS WERE CUT, MY BUSINESS EARNED LESS].
Household member Employer or business Expected in [YEAR]
[NAME] [EMPLOYER OR BUSINESS] $[AMOUNT]
[NAME] [EMPLOYER OR BUSINESS] $[AMOUNT]
Total $[ANNUAL INCOME]
I am sending these documents with this letter:
[DOCUMENT, FOR EXAMPLE: MY LAST TWO PAY STUBS]
[DOCUMENT, FOR EXAMPLE: SELF-EMPLOYMENT LEDGER FROM JANUARY 1 TO OCTOBER 31]
This information is true to the best of my knowledge.
[SIGNATURE]
[FULL NAME]