INCOME VERIFICATION AGREEMENT
Prepared by OnePoint Insurance Agency – Legal Document for Client Execution
Agency Address:
OnePoint Insurance Agency
555 North Point Center E, Suite 400
Alpharetta, GA 30022
Phone: (888) 899-8117
This legally binding agreement (“Agreement”) is entered into and effective as of the date signed below by and between:
AND
Agent Name: Vera Orji
Agency: OnePoint Insurance Agency
National Producer Number (NPN): 18473185
1. Purpose of Agreement
This Agreement documents and confirms that the client has voluntarily provided projected annual income information for the purpose of determining eligibility for subsidized health insurance coverage through the Federal Health Insurance Marketplace (HealthCare.gov) under the Patient Protection and Affordable Care Act (ACA). This declaration will be used to determine eligibility for Advance Premium Tax Credits (APTCs) and Cost-Sharing Reductions (CSRs) as defined under 26 U.S. Code § 36B and 42 U.S. Code § 18071.
2. Client's Income Declaration
The undersigned client hereby affirms the following:
The estimated household Modified Adjusted Gross Income (MAGI) for the upcoming coverage year is:
This projection includes all taxable sources of income as defined by the Internal Revenue Code (e.g., wages, self-employment, unemployment compensation, Social Security income, alimony (as applicable), and investment income).
This income was directly provided by the client and not inferred or altered by the agent or OnePoint Insurance Agency.
3. Legal Acknowledgements and Consequences
By signing this Agreement, the client expressly acknowledges:
Eligibility for federal subsidies is contingent on accurate income reporting and is subject to reconciliation when the client files their IRS Form 8962 during the annual tax filing process.
Any discrepancy between reported income and actual income may result in:
Repayment of APTCs
Denial of future subsidies
Tax liabilities, penalties, or IRS enforcement
The client affirms understanding that fraudulent misrepresentation of income may constitute a federal offense under 18 U.S.C. § 1001 and related provisions.
4. Duty to Update Information
The client agrees and warrants to:
Notify OnePoint Insurance Agency within 15 calendar days of any substantial income change or household change (e.g., job gain/loss, marriage, birth, loss of dependent).
Complete and submit an Income Update Form to OnePoint Insurance Agency upon such notification.
Understand that failure to report such changes may result in legal and financial consequences, including, but not limited to, owing back subsidies to the federal government.
5. Agency’s Limitation of Liability
OnePoint Insurance Agency and its licensed agents:
Serve only as facilitators of the client’s application based on information provided by the client.
Do not bear responsibility for inaccurate or outdated information submitted by the client.
Are hereby held harmless and indemnified by the client from any financial or legal repercussions stemming from misreported income or failure to report income changes.
6. Governing Law and Legal Intent
This Agreement shall be governed by and construed in accordance with the laws of the State of Georgia and applicable federal statutes. This Agreement is intended to be legally enforceable and may be used as evidence in a court of law to demonstrate that the client:
Provided income estimates knowingly and voluntarily;
Acknowledged the legal consequences of misreporting or failing to update said information.
7. Signatures
By signing below, the parties confirm that they have read, understood, and agree to be bound by the terms of this Agreement.
Client Signature:
By providing your information today, you authorize OnePoint Insurance Agency to collect, transmit, and use the personal, vehicle, and driver details you've provided to obtain insurance quotes from one or more licensed insurance carriers.
You also consent to us contacting you by phone, email, or text regarding your insurance options, and to share your data securely with insurers for the purpose of evaluating eligibility, pricing, and coverage options.
This does not bind you to any policy or payment, and you are under no obligation to purchase. We respect your privacy and will not sell your information.
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