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OMB No. 09381378 Expires: 7/31/2023EXHIBIT 1: MODEL INDIVIDUAL ENROLLMENT REQUEST FOR MTO ENROLL IN A MEDICARE ADVANTAGE PLAN (PART C) MEDICARE PRESCRIPTION DRUG PLAN (PART D)Who can use this form?

How to fill out exhibit 1 model individual

How to fill out exhibit 1 model individual

1. To fill out exhibit 1 model individual, follow these steps:
2. Start by entering your personal information, such as your full name, address, and contact details.
3. Provide information about your occupation, including your job title, employer's name, and address.
4. Fill in details about your income, such as your annual salary or wages, bonuses, commissions, and any other sources of income.
5. Include information about your assets, such as bank accounts, investments, real estate properties, vehicles, and any other valuable possessions.
6. Specify your liabilities, including mortgages, loans, credit card debts, and any other financial obligations.
7. If applicable, provide details about your dependents, such as your spouse and children, including their names, ages, and relationship to you.
8. Review the completed exhibit 1 model individual form for accuracy and make any necessary corrections.
9. Sign and date the form to certify that all the information provided is true and accurate.
10. Submit the filled-out exhibit 1 model individual form as per the instructions provided.

Who needs exhibit 1 model individual?

1. Exhibit 1 model individual is typically needed by individuals who are required to provide detailed information about their personal and financial circumstances. This may include individuals involved in legal proceedings, such as divorce or child custody cases, individuals applying for certain types of loans or credit, individuals seeking to establish their financial status for taxation purposes, or individuals involved in insurance claims or settlements.

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What is exhibit 1 model individual?

Exhibit 1 model individual is a form required to be filed by certain individuals with specific financial interests.

Who is required to file exhibit 1 model individual?

Individuals with financial interests meeting certain criteria are required to file exhibit 1 model individual.

How to fill out exhibit 1 model individual?

Exhibit 1 model individual can be filled out online or submitted in physical form following the instructions provided by the relevant authority.

What is the purpose of exhibit 1 model individual?

The purpose of exhibit 1 model individual is to provide transparency and disclosure of potential conflicts of interest related to financial holdings.

What information must be reported on exhibit 1 model individual?

Information such as financial assets, investments, income sources, and other financial interests must be reported on exhibit 1 model individual.