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If you are filing this form for a different tax year, please refer to the department's website. |  |  |\n| --- | --- | --- |\n| Name (if filing jointly, use name shown first on the PA-40) |  | Social Security Number |\n| PURPOSE: The purpose of the REV-1882, Health Insurance Coverage Information Request, is to connect uninsured Pennsylvanians with information regarding their eligibility to enroll in health insurance coverage through the Pennsylvania Health Insurance Exchange Authority, also known as Pennie® . Pennie is Pennsylvania’s health insurance marketplace. The Pennsylvania Department of Revenue and Pennie have teamed up to gather information from residents who do not have health insurance coverage, making it easier to apply and enroll in comprehensive health insurance through Pennie. If you, your spouse (if married, filing jointly), or any dependents in your household are uninsured, make sure to answer the questions below. By answering the questions below, you are giving permission for the Pennsylvania Department of Revenue to share information from your state tax return (such as your household size and income) with Pennie, and for Pennie to send you postal mail with personalized information regarding your ability to enroll in low-cost or no cost health insurance coverage. |  |  |\n| Email Address |  |  |\n| \u003Cbr>|  |  |\n| Phone Number | |  |\n\n1. Select oval if you do not have health insurance coverage    \n2. Select oval if your spouse (if married, filing jointly) does not have health  \ninsurance coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  \n3. Select oval if any dependents included on your federal tax return do not have health  \ninsurance coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  \n4. Select oval if you consent to allow the Pennsylvania Department of Revenue to share information from your PA-40 tax return and the REV-1882 with Pennie.    \n5. Select oval if you consent to allow Pennie to communicate with you via phone or email    \n6. Please provide your adjusted gross income from Line 11 of your federal tax return    \n1.   \n2.   \n3.   \n4.   \n5.   \n6.  s  s    \n7. Please provide the number of household members included on your federal tax return . . . . . . . 7.  \n8. Please provide the date of birth for yourself, your spouse (if married, filing jointly), and all tax dependents under age 26 within your household who do not have health insurance coverage.  \n\n| Taxpayer Date of Birth (MM/DD/YYYY) | Spouse Date of Birth (if married, filing jointly)(MM/DD/YYYY) |\n| --- | --- |\n\nDependent(s) Date(s) of Birth (MM/DD/YYYY)  \n\n|  |  |\n| --- | --- |\n|  |  |\n|  |  |\n|  |  |\n|  |  |\n\n2310010059  \n2023  \nInstructions for REV-1882  \nHealth Insurance Coverage Information Request  \nREV-1882 IN (EX) 03-23  \nGENERAL INFORMATION  \nThe Pennsylvania Health Insurance Exchange Authority, also known as Pennie® , is Pennsylvania’s state-based health insurance marketplace providing Pennsylvanians with access to affordable health insurance. Pennie has partnered with the Pennsylvania Department of Revenue to establish a program whereby Pennsylvanians can provide eligibility information to Pennie while filing their Pennsylvania Income Tax return.  \nPURPOSE OF FORM  \nThe purpose of the REV-1882, Health Insurance Coverage Information Request, is to provide uninsured Pennsylvanians with a way to submit information to Pennie. Pennie will use this information to assist you in determining your eligibility for enrollment in health insurance with financial assistance. For additional information regarding Pennie, please visit [www.pennie.com](www.pennie.com).  \nIf you are uninsured and want to understand your eligibility for health insurance thro","cbCainNAuP6tjEU6","https://ap.wps.com/l/cbCainNAuP6tjEU6","pdf",91467,"English","# Purpose of the Form\n# When to Complete and Consent\n# Form Instructions\n## Line Instructions","[{\"question\":\"What permissions does the form grant regarding information sharing?\",\"answer\":\"By answering the questions, the filer authorizes the Pennsylvania Department of Revenue to share tax return information (such as household size and income) with Pennie, and authorizes Pennie to send personalized information by postal mail, and—if consented—by phone or email.\"}]","HEALTH INSURANCE COVERAGE INFORMATION REQUEST - 2023 | PDF",1789794007]