Waiver Acknowledgement:

By signing this form, I grant appointed agents with Blue Cross Blue Shield the right to use the above information as needed to navigate and enroll in the Federally-Facilitated Marketplace. I further agree that the information listed is true and accurate to the best of my knowledge.

If any of the above information changes: I understand that it may impact my ability to obtain a premium tax credit. I also understand that when I file my federal income tax return, the Internal Revenue Service (IRS) will compare the income on my tax return with the income on my application. I understand that if the income on my tax return is lower than the amount of income on my application, I may be eligible to get an additional premium tax credit amount. On the other hand, if the income on my tax return is higher than the amount of income on my application, I may owe additional federal income tax.