Quote Request for Covered California
Contact Information
Name
Phone Number
Email
Number of people in the household
Household Income
Check One
Annual
Monthly
Biweekly
Weekly
Hourly
How to calculate
Household Income?
Zip Code
Age of every adult in household over 18
Adult 1 (over 18)
Adult 2 (over 18)
Your household income
is based on what you file
with the IRS on your 1040
form. See back for further
explanation.
Adult 3 (over 18)
Adult 4 (over 18)
Adult 5 (over 18)
Number of dependents age 18 or under
Check One
0
1
2
3 or more
*OPTIONAL*
Name of Preferred Primary Doctor
First, Last
Toll Free (800) 568-4500 • Phone (916) 686-4500 • Fax (916) 686-4514 • rlwells99@frontiernet.net
www.rlwellsinc.com
refund.
Filing Status
Check only one
box.
Exemptions
1
2
3
4
Single
Married filing jointly (even if only one had income)
Married filing separately. Enter spouse’s SSN above
and full name here. ▶
6a
b
c
social security number
Last name
the qualifying person is a child but not your dependent, enter this
child’s name here. ▶
5
Qualifying widow(er) with dependent child
}
qualifying for child tax credit
(see instructions)
relationship to you
Dependents on 6c
not entered above
d
Attach Form(s)
W-2 here. Also
attach Forms
W-2G and
1099-R if tax
was withheld.
If you did not
get a W-2,
see instructions.
Enclose, but do
not attach, any
payment. Also,
please use
Form 1040-V.
Adjusted
Gross
Income
Boxes checked
on 6a and 6b
No. of children
on 6c who:
• lived with you
• did not live with
you due to divorce
or separation
(see instructions)
If more than four
dependents, see
instructions and
check here ▶
Income
Spouse
Head of household (with qualifying person). (See instructions.) If
Yourself. If someone can claim you as a dependent, do not check box 6a . . . . .
Spouse
. . . . . . . . . . . . . . . . . . . . . . . .
(4) ✓ if child under age 17
(2) Dependent’s
(3) Dependent’s
Dependents:
(1) First name
You
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8b
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8a
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9a
10
11
Qualified dividends . . . . . . . . . . .
9b
Taxable refunds, credits, or offsets of state and local income taxes
Alimony received . . . . . . . . . . . . . . .
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10
11
12
13
14
Business income or (loss). Attach Schedule C or C-EZ . . . . . . . . .
Capital gain or (loss). Attach Schedule D if required. If not required, check here ▶
Other gains or (losses). Attach Form 4797 . . . . . . . . . . . . .
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12
13
14
15a
16a
17
IRA distributions .
15a
b Taxable amount
. . .
Pensions and annuities 16a
b Taxable amount
. . .
Rental real estate, royalties, partnerships, S corporations, trusts, etc. Attach Schedule E
15b
16b
17
18
19
20a
Farm income or (loss). Attach Schedule F .
Unemployment compensation . . . .
Social security benefits 20a
18
19
20b
21
22
Other income. List type and amount
Combine the amounts in the far right column for lines 7 through 21. This is your total income
23
Educator expenses
24
Certain business expenses of reservists, performing artists, and
fee-basis government officials. Attach Form 2106 or 2106-EZ
25
Health savings account deduction. Attach Form 8889
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24
25
26
27
28
Moving expenses. Attach Form 3903 . . . . . .
Deductible part of self-employment tax. Attach Schedule SE .
Self-employed SEP, SIMPLE, and qualified plans
. .
26
27
28
29
30
31a
Self-employed health insurance deduction
Penalty on early withdrawal of savings . .
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32
33
34
Alimony paid b Recipient’s SSN ▶
IRA deduction . . . . . . .
Student loan interest deduction . .
Tuition and fees. Attach Form 8917 .
29
30
31a
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32
33
34
35
36
37
Domestic production activities deduction. Attach Form 8903
35
Add lines 23 through 35 . . . . . . . . . . . . .
Subtract line 36 from line 22. This is your adjusted gross income
7
8a
b
9a
b
Total number of exemptions claimed
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Wages, salaries, tips, etc. Attach Form(s) W-2
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Taxable interest. Attach Schedule B if required .
Tax-exempt interest. Do not include on line 8a .
Ordinary dividends. Attach Schedule B if required
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b Taxable amount
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Add numbers on
lines above ▶
7
21
22
23
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For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions.
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36
37
Cat. No. 11320B
Form
1040
Use the Total on
line 37 for the Covered
California quote.
(2012)