• I hereby decline enrolling in a health plan for 2014. I understand that by declining to enroll now, my family and I may not be able to enroll in a health plan until January 1, 2015. Furthermore, I may be subject to a tax penalty for 2014 for failing to have minimum essential coverage.*

  • * Consult your tax adviser for more information regarding the IRS individual shared responsibility provision.

  • Please confirm you are declining to enroll in health coverage for 2014 by using the electronic pen and singing your name below.