Home address     ( 家庭住址,    Dirección de la casa )

Phone number      ( 電話號碼,    número de teléfono ) 

Email address     ( 電子郵件,    Email Dirección )  

   Please add your note into box below  請填寫你的註釋到下面的notebox框中:
 
   After finished, click Submit (at bottom) to send. We will email you a quote within 24 hours and maybe call you for the quote.

Family Income: If you apply for financial aid for health insurance, we need your family income data. Please fill in your family income Last Month (2020 or 2021) total $__________, and projected year 2021 total $__________. For data verification, we need copy of last month payroll pay-stubs, 2019 or 2020 W-2 and tax return Form1040 (first two pages).

家庭收入:  請填寫您的家庭上個月 (2020 or 2021) 收入總額 ，估算2021年一年收入總額 . 為了查證數據, 我們需要複印您的家庭上個月的所有工資支票存根, 去年(2019 or 2020) 所有的W-2和家庭報稅表1040(第1, 2頁).

Additional requests (其他要求):

1.)      If someone is a college student, please provide costs of annual total tuition and fees (Form 1098-T); if someone pays back a student loan, also provide annual interest payment of the loan.

如果有人是大學生，請提供全年學費和雜費的費用;如果有人回付學生貸款，提供每年支付貸款的利息.

2.)      If your family has other incomes besides of wages and self-employed incomes, please list net profit for each of them with category name.

如果你的家庭,除了工資,有其他收入和自僱收入，請列出每個人的收入和名稱類別, 自僱收入的淨利潤與名稱.

3.)      If someone has a current health insurance, please make copy of the insurance card with carrier name, address, phone number, and policy number.

如果有人有醫療保險，請複印保險卡,含運營商名稱，地址，電話號碼和保單的號碼.

4.)      Please list each employer name, address, and phone number for each family member.

請列出每個家庭成員的每個雇主名稱，地址, 和電話號碼.

5.)      Please make copy of each greencard for both front and back sides.

請複印每個綠卡的正面和背面.

6.)      If a US citizen who was not born in the US, please list the person name with the original greencard number and the certificate number of naturalization.

如果美國公民不是出生在美國，請列出此人的名字與原來的綠卡號碼和入籍證書編號.

附件，申請優惠健康保險時，需要的文件清單的樣例(點擊下面的鏈接)：

聯邦政府需要的文件清單: 1.)移民身份 2.) 家庭收入 3.)OHP需要的 低收入證明

Tips: Use your cell phone to take pictures of documents and email the pictures to us: hwu475@gmail.com. Also, for your data safety (not to send online), you may use your cell phone to take a 'screen shot', after filled in all your family data, and then email the picture to us.

溫馨提示：使用您的手機給所有文件拍照,並通過電子郵件將照片發送給我們: hwu475@gmail.com. 此外，為您的數據安全(不在網上發送), 在填充了您的所有家人的數據後, 可以用您的手機對著屏幕拍照, 然後將圖片通過電子郵件發送給我們。

Agreement: I am (print name 填寫您的姓名). I agree to provide my family personal data (birthday, SSN, income, etc.) for Henry Hu Agency to assist me to apply for benefits of health insurance. I know the data will be forwarded to US government and I agree to take full responsibility for the data I provided. Henry Hu Agency will keep the data confidential for applying insurance only and protect privacy of all applicants.

獲得確認號碼：為了確保我們收到您的申請(Fact Find), 提交您的申請後(點擊按鈕"Submit Fact Find"), 請撥打我們的手機 (503) 475-4705獲得我們的確認號碼。謝謝您的合作。