Marketplace Appeal Request EAII Form Marketplace Appeal Request EAII Form (06 2019)-2026

1. Click ‘Get Form’ to open the Marketplace Appeal Request EAII Form in the editor.
2. Begin by filling out the personal information for each person whose eligibility is being appealed. Include their first name, last name, date of birth, daytime phone number, and address. If there are more than four individuals, use additional paper.
3. In the 'Reason for the appeal' section, enter your Application ID and the date on your Marketplace Eligibility Notice. Clearly explain why you believe the decision regarding your financial help is incorrect.
4. If applicable, indicate if you need to expedite your appeal due to health reasons and provide a brief explanation.
5. Attach any supporting documents that demonstrate income sources for everyone listed on your application. Ensure these documents are copies and dated within two years.
6. All tax filers aged 18 and older must sign the form to authorize sharing of federal tax information. Each signature should be accompanied by printed names and dates.
7. Finally, mail or fax your completed form along with any documents within 90 days of your notice date to the specified address.

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