Tip for Marketplace-specific

Report income changes throughout the year — don't wait for the verification notice

Tip for Marketplace-specific

Over-estimating income means a smaller monthly subsidy but a refund at tax time; under-estimating means a larger monthly subsidy but you may owe at tax time

Tip for Marketplace-specific

Self-employed? Use your net self-employment income (after deductions) as your projected income

ACA Marketplacemoderate

Income Verification / Data Matching Response

Marketplace-specific · Marketplace

Documentation resolving income discrepancies between application and IRS data. Failure to respond may result in APTC adjustment or loss of coverage.

Form Details

Total fields: 15
Auto-fillable: 10 (67%)
Time without BeneFill: 30 minutes
Time with BeneFill: 8 minutes
Time saved: 22 minutes
Filled by: patient
Frequency: as needed

Fill this form with BeneFill

Auto-fill 67% of fields from your profile. Save 22 minutes. Download a real PDF.

10 of 15 fields67% auto-filled

Start Filling Upload Your Copy Instead

Where to Submit This Form

🌐

Upload through your Marketplace account

https://www.healthcare.gov/verify-information/

Go to your application and look for the documents section.

📬

Mail to the Marketplace

Health Insurance Marketplace Department of Health and Human Services 465 Industrial Blvd London, KY 40750-0001

📠

Fax to the Marketplace

Fax: 1-855-365-5535

Filing Deadline

Typically 90 days from enrollment. You will receive a notice specifying the exact deadline. Missing it may result in loss of premium tax credits.

Required Attachments

📎 Most recent federal tax return (Form 1040)
📎 Pay stubs from the last 30 days
📎 W-2 forms from the most recent tax year
📎 Self-employment income documentation (if applicable)
📎 Social Security benefit letter (if applicable)
📎 Unemployment compensation documentation (if applicable)

Processing Time

10-30 days. Your premium tax credit amount may be adjusted based on verified income.

What Happens Next

The Marketplace will verify your income and adjust your Advance Premium Tax Credit (APTC) accordingly. If your income is higher than projected, your subsidy may decrease. If lower, it may increase.

Tips for This Form

✓ Report income changes throughout the year — don't wait for the verification notice
✓ Over-estimating income means a smaller monthly subsidy but a refund at tax time; under-estimating means a larger monthly subsidy but you may owe at tax time
✓ Self-employed? Use your net self-employment income (after deductions) as your projected income
✓ If you cannot provide the requested documents, call the Marketplace — alternative documentation may be accepted

More ACA Marketplace Forms

State-Based Marketplace Application

State-specific (CA, NY, CO, etc.) · State-based marketplaces

State-specific marketplace application in states operating their own exchanges (17 states + DC).

Special Enrollment Period (SEP) Verification

Marketplace-specific · Marketplace

Documentation of qualifying life event (job loss, marriage, birth, move) for enrollment outside open enrollment. Must enroll within 60 days of qualifying event.

Not sure which forms you need?

Tell our assistant about your situation and we'll find the right forms for you.

Chat with Form Assistant

Disclaimer: BeneFill™ provides form-filling assistance and informational guidance only. It is not affiliated with, endorsed by, or sponsored by the Marketplace or any government agency. The information provided is for general informational purposes and does not constitute legal, medical, financial, or tax advice. Always verify form requirements and submission details directly with the issuing agency.