Understanding the Acknowledgment for Sole Proprietorship form is crucial for small business owners seeking health coverage for themselves and their dependents. This comprehensive document serves several key functions: it verifies the legal and operative status of the business, outlines the eligibility requirements for health insurance coverage, and sets forth the attestation of the sole proprietor or the sole shareholder of an S-Corporation. The form requires detailed business information, including the organization's name, tax identification, primary business activity, and contact details. The attestation portion is where the business owner asserts that their enterprise does not fall under prohibited categories, confirms their role and work commitment in the business, and declares their income source. Additionally, for those in specific organizational structures like S-Corporations, similar attestation requirements are highlighted, emphasizing the sole employment and shareholder status. Signatories are also obliged to provide tax documentation upon request to verify the claims made within the form. Importantly, this form acts as a legal document, where providing false information could lead to severe penalties, underscoring its significance in the process of obtaining health coverage. Executing this form accurately and truthfully is thus vital, ensuring that small business owners and their dependents can access health insurance benefits without complication.
| Question | Answer |
|---|---|
| Form Name | Aknowledgement For Sole Propritorship Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | sole group attestation, nys dba form sole proprietor, new ny 07 134 sole proprietor, sole propietor certficate on tax form |
Sole Proprietor and Group of One Attestation Form
I. Business Organization Information:
a. Name of Organization: Tax ID # or SS #:
Primary Business Activity
Address:
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b. Contact Information for Business Organization |
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II. Sole Proprietor Attestation:
By executing this document, I hereby attest that: (i) the above described business organization is not an association, group purchasing organization or employee leasing organization and was formed for a lawful business purpose and not for the primary purpose of obtaining group insurance; (ii) I am the owner and operator of the above described business organization; (iii) I work a minimum of twenty (20) hours per week for this business organization; I derive the majority of my earned income
III.
By executing this document, I hereby attest that: (i) the above described business organization is not an association, group purchasing organization or employee leasing organization and was formed for a lawful purpose and not for the primary purpose of obtaining group insurance; (ii) I am the sole shareholder of the above described business organization; (iii) I am currently employed by the above described business organization and work a minimum of twenty (20) hours per week for the business organization; (iv) I derive the majority of my earned income
IV. Tax Forms and other Documents (applicable to both Sole Proprietors and
By executing below, I agree to provide upon request appropriate tax forms to Oxford to validate the eligibility status. Before application will be considered, the applicant must execute this Attestation Form and provide the tax information and related documents indicated on the attached correspondence. Oxford reserves the right to modify these documentation and eligibility requirements in the future.
The undersigned certifies that, to the best of his or her knowledge and belief, and under penalty of perjury, the information listed above is true and complete.
X.
Signature of Applicant |
Date |
Insurance products are underwritten by Oxford Health Insurance, Inc.
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each violation.
9503 R2 |