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
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.) ________________ _______
_____________________ _____________________________ ____________________________ __________
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: __________
: ________ ___________________________________________ App Reg./Case # : _______________________
Social Security Number: _______________________
City: ______________ _________________________ State: _______________________ Zip Code: _______________