Fillable appeal form

Gov/marketplace-appeals to Get an appeal request form for other states. Learn more about Marketplace appeals. Page 1 of 4 Appeal Request Form Individual Please print in capital letters using black or dark blue ink only. The authorization is valid until the earlier of The resolution of the appeal or My written notification that I want any or all of my authorized representatives removed from this appeal. I m signing this form under penalty of perjury which means I ve provided true answers to all the questions and I ve answered to the best of my knowledge. Gov/marketplace-appeals/shop-decisions/. Timeframe to request an appeal If you applied in one of the states listed above you must submit your appeal request within 90 days of the date...