Verify Zero Income Form

Affidavit to Verify
Zero Income
When you send us this form, please include a copy of the letter that we sent you asking for proof of your income. The letter is called a “Request for Information.
When you send us this form, please include a copy of the letter that we sent you asking for proof of your income. The letter is called a “Request for Information.
STEP 1
Tell us about yourself. Please print.
Name

First nameMiddle initialLast name
Middle initial
Date of birth (MM/DD/YYYY)
Date of birth (MM/DD/YYYY)
Ref ID
Social Security number
MassHealth ID
(optional)
STEP 2
I do not receive any income at this time. By signing below, I swear under the pains and penalties of perjury that everything on this form is true and complete to the best of my knowledge. I know that if I lie on this form, my health coverage might end and I might have to repay Massachusetts for any tax credits or health benefits I got.
Applicant, member, or authorized representative signature
(MM/DD/YYYY)
(MM/DD/YYYY)
(MM/DD/YYYY)
STEP 3
Return this signed form in one of these 3 ways.
2. Mail: Health Insurance Processing Center P.O. Box 4405 Taunton, MA 02780

3. In person: MassHealth Enrollment Centers
Health Connector Walk-in Centers
45 Spruce Street Chelsea, MA 02150

21 Spring Street, Suite 4 Taunton, MA 02780

133 Portland Street Boston, MA 02114

100 Hancock Street, 6th Floor Quincy, MA 02171

367 East Street Tewksbury, MA 01876

63 Main Street Brockton, MA 02301
88 Industry Avenue, Suite D Springfield, MA 01104

The Schrafft Center 529 Main Street, Floor M Charlestown, MA 02129

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 TTY: (800) 497-4648.
Should be Empty:

Affidavit to Verify

STEP 1

Health Connector Walk-in Centers

Questions?