Attestation-Form-to-Verify-Income

Attestation Form to Verify Income

Fill out this form if you cannot provide the documentation needed to verify your income. You should always try to provide formal documentation if you can. See income verifcation documents types at https://www.mahealthconnector.org/verifcation-documents. This form will be accepted if an individual has made a good-faith effort to get income documentation but cannot due to the examples below. You may use this form if:
- getting the needed documentation poses a safety risk to you,
- accessing the document is impossible due to circumstances outside of your control, or
- you have sent documentation that has repeatedly been rejected and you have no other acceptable proof of this type of income
Head of Household Name
Other Household Members
Reference ID/Member ID
Phone Number
Today’s Date

MonthDayYear
Date
What is your total expected income for the current calendar year as stated on your application
Select one option below: I am completing this form because:
Review the types of income listed in your Request for Information. Below, check off the types of income listed in your letter.

1. I cannot access documentation to prove my income Examples: The document is being withheld or you will not have documentation2. Documentation to prove my income does not existProof of Job Income including employer,Proof of Income from Capital GainsProof of Alimony ReceivedProof of Income from Canceled DebtsProof of Self Employment IncomeProof of Income from Interest, Dividends,Proof of Income from Court AwardsProof of Social Security BeneftsProof of Income for Jury Duty PayProof of Unemployment IncomeProof of Rental or Royalty IncomeProof of Other Income from other sourceProof of Retirement or Pension IncomeProof of Farming or Fishing IncomeProof of Other Income from other source
job name, address, hours worked)
Income Detail – for each income type listed on the Request for Information you received in the mail, include the dollar amount received and the frequency with which it is received monthly, quarterly, seasonally, or one time only
Explanation for Income – please provide as much detail on your projected income above as possible, including reasons for any changes in income type, changes in income source or frequency, date of change, etc.
- to include, is true and complete to the best of my knowledge.
- health benefts I got.
Date

MonthDayYear
Date
RETURN THIS SIGNED DOCUMENT IN ONE OF FOUR WAYS
- Upload to your HIX account
- FAX it to (857) 323-8300
- Mail it to Health Insurance Processing Center, PO Box 4405, Taunton, MA 02780 • Give this form to someone at one of these locations MassHealth Enrollment Centers
Health Connector Walk-in Centers

529 Main Street Charlestown, MA 02129 88 Industry Avenue, Suite D Springfeld, MA 01104 21 Spring Street, Suite 4 Taunton, MA 02780

367 East Street Tewksbury, MA 01876

133 Portland Street Boston, MA 02114 146 Main Street Worcester, MA 01608
QUESTIONS
Call the Health Connector at (877) MA ENROLL, (877) 623-6765 or TTY: (877) 623-7773. Or call MassHealth at (800) 841-2900 or TDD/TTY: 711.
Should be Empty:

RETURN THIS SIGNED DOCUMENT IN ONE OF FOUR WAYS

QUESTIONS