Fillable Printable Self-declaration of Income - New York

Self-declaration of Income - New York

Attachment V

NEW YORK STATE DEPARTMENT OF HEALTH

Office of Health Insurance Programs Self- Declaration of Income

Complete the information below only if y ou have no other way to document y our income. All of the boxes

belo w must be checked and all questions answered. Failure to complete this form may result in denial of your

application.

I get paid in cash.

I do not get pay checks.

I do not get pay stubs.

I cannot get a letter from my employer. Explain why: _____________________________________________________

_______________________________________________________________________________________________

My cash income is $_____ ________________ How often (weekly, monthly etc.) ________________ _______

Current Employer:

_____________________ _____________________________ ____________________________ __________

Applicants/Recipients must read the following and sign below

I certify that I have no other way to document my income and that all of the above information is true and co rrect. I

understand that this information is to be used to determine eligibility for Public Health Insurance Programs. I

understand that program officials may verify information on this form. I also understand that if I intentionally

misrepresent my income, I may have to repay benefits received and may be prosecuted und er State law.

Signature of Applicant: __________ _______________________________________ Date: _____________________

Facilitated Enrollers must read the following and sign below

I certify that I asked the applicant/recipient about all sources of income received by the household and, before using this

form, used best efforts to o btain other possible sources of documentation. The information reported on this form was

provided solely by the applicant/recipient and reflects the income the applicant reported to me. I did not modify the

information in any way. I understand that if I intentionally falsified information on this form or if I assiste d the applicant in

falsifying any information, I may lose my job and may be prosecuted unde r State law.

Name: ________ ________________________ Signature: _______________________________ Date: __________

Name

: ________ ___________________________________________ App Reg./Case # : _______________________

Social Security Number: _______________________

Address: _________________________________________________________________________________________

City: ______________ _________________________ State: _______________________ Zip Code: _______________

DOH-4444 (0X/10)