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Follow the simple instructionsįeel all the advantages of submitting and completing forms on the internet. Enjoy smart fillable fields and interactivity. Get your online template and fill it in using progressiveįeatures. How to fill out and sign Self declaration of income online? Signature of Applicant Date Facilitated Enrollers must read the following and sign below obtain 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 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 under State law. I understand that this information is to be used to determine eligibility for Public Health Insurance Programs. 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 correct. All of the boxes below 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 understand that if I intentionally falsified information on this form or if I assisted the applicant in falsifying any information I may lose my job and may be prosecuted under State law. I did not modify the information in any way. Reg/Case Social Security Number XXX-XXAddress STREET CITY STATE ZIP CODE Complete the information below only if you have no other way to document your income. NEW YORK STATE DEPARTMENT OF HEALTH Office of Health Insurance Programs Self-Declaration of Income Name App.

Self declaration of income form