Get Peehip Fpl 514 2g F P Level A Fpl Active Or - Rsa-al

The PEEHIP FPL 514 2G F P LEVEL A FPL ACTIVE OR - Rsa-al form is essential for users seeking Federal Poverty Level Premium Assistance through the Public Education Employees' Health Insurance Plan. This guide will walk you through the process of filling out the form online, ensuring you understand each section and the necessary details required for successful submission.

Follow the steps to accurately complete the PEEHIP FPL 514 form online.

1. Press the ‘Get Form’ button to access the document and open it for editing.
2. Enter your personal information in the 'PEEHIP Subscriber Information' section. Ensure your name matches exactly with what is shown on your Social Security card, and include your Social Security Number or PID Number.
3. Fill in your first name, middle name or initial, last name, and mailing address. Be sure to provide your city, state, ZIP code, and home and work phone numbers.
4. Indicate your marital status by checking the appropriate box — options include single, married, divorced, legally separated, or widowed.
5. Attach a signed copy of your previous year's Federal Income Tax Return Form 1040, 1040A, or 1040EZ, along with all relevant supporting 1099 and W-2 forms. If you were married but did not file jointly, you must include your spouse’s tax return as well.
6. Complete the 'PEEHIP Subscriber Certification' section by signing and dating the form to confirm that all information is true and complete.
7. If applicable, have your spouse sign and date the form in the designated area.
8. Once all fields are filled, review the form for any errors or omissions, save your changes, and then download or print the completed application for submission.
9. Mail the completed form to the address provided at the top of the document.

Submit your application online to receive Federal Poverty Level Premium Assistance without delay.