Calculate Your Applicable 2014 Second Lowest Cost Silver Plan Monthly Medical Premium

Complete the information below for each person in your tax household. For each person, check each month they enrolled in medical insurance through the Connector:

Name/NicknameDate of Birth (MM/DD/YYYY)Relationship to Primary Tax FilerAll of 2014Jan 2014Feb 2014Mar 2014Apr 2014May 2014Jun 2014Jul 2014Aug 2014Sep 2014Oct 2014Nov 2014Dec 2014