Skip to main content
Supplemental Tax Questions for MAGI Applications
Applicant name
Case number
Name of household individual column 1
Federal income tax filing status for individual column 1
Single
Married Jointly
Married Separately
As a dependent
Not Filing
Tax dependents claimed by individual column 1
Outside household tax claimant and relationship for individual column 1
Name of household individual column 2
Federal income tax filing status for individual column 2
Single
Married Jointly
Married Separately
As a dependent
Not Filing
Tax dependents claimed by individual column 2
Outside household tax claimant and relationship for individual column 2
Name of household individual column 3
Federal income tax filing status for individual column 3
Single
Married Jointly
Married Separately
As a dependent
Not Filing
Tax dependents claimed by individual column 3
Outside household tax claimant and relationship for individual column 3
Name of household individual column 4
Federal income tax filing status for individual column 4
Single
Married Jointly
Married Separately
As a dependent
Not Filing
Tax dependents claimed by individual column 4
Outside household tax claimant and relationship for individual column 4
Name of household individual column 5
Federal income tax filing status for individual column 5
Single
Married Jointly
Married Separately
As a dependent
Not Filing
Tax dependents claimed by individual column 5
Outside household tax claimant and relationship for individual column 5
Date permission is provided