Omb no 0938 1191: Fill out & sign online

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Click ‘Get Form’ to open the OMB No. 0938-1191 application in the editor.
Begin by filling out Step 1, which requires personal information. Enter your first name, middle name, last name, and suffix. Provide your home address, city, state, ZIP code, and county.
Continue with your contact details including phone numbers and email preferences. Indicate if you need health coverage for yourself and provide your Social Security number and date of birth.
Move to Step 2 to include additional individuals needing health coverage. Repeat the process for each person by entering their names, relationships, Social Security numbers, and other relevant details.
In Step 3, indicate if anyone in your family is American Indian or Alaska Native. If yes, provide their names and tribe information.
Complete the application by signing in Step 4 under penalty of perjury. Ensure all information is accurate before submitting.
Finally, mail your completed application to the specified address provided in Step 5.

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