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Legal First and Last Name *
Date of Birth *
MM
/
DD
/
YYYY
Zip Code *
Phone *
Email *
Do you file your taxes as: *
Do you have or claim and dependents on your taxes? *
How many dependents do you claim on your taxes?
Employment Status *
Estimated Annual Income
(Multiply your last weekly/bi-weekly paycheck x (Weekly x16, Jan-April, 16 pay periods, Bi-Weekly x8, 8 pay periods). That is your annual income that you have earned so far. *
I authorize my agent (Michael Blackton) to search, access and submit my application on my behalf, submit  any necessary documents, keep me updated through phone text or email, and to follow-up with me to update my application and carryover these benefits into the following year. I also confirm that if my profile indicates Medicaid or Medicare coverage, I authorize my agent to submit the necessary documentation confirming that I am not enrolled in those programs. *
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