Form Doh-4444 - Self- Declaration Of Income printable pdf download

Attachment V

NEW YORK STATE DEPARTMENT OF HEALTH

Self- Declaration of Income

Office of Health Insurance Programs

Name

___________________________________________________ App Reg./Case # : _______________________

Social Security Number: _______________________

Address: _________________________________________________________________________________________

City: _______________________________________ State: _______________________ Zip Code: _______________

Complete the information below only if you have no other way to document your income. 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 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 correct. 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 under 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 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 did not modify the

information in any way. 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.

Name: ________________________________ Signature: _______________________________ Date: __________

DOH-4444 (0X/10)

Form Doh-4444 - Self- Declaration Of Income