Form Aca-3 - Massachusetts Application For Health And Dental Coverage And Help Paying Costs - Masshealth Form Page 7
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32Person 1 (continued)
STEP 2
|
CURRENT JOB 1
19. Employer name and address
Federal Tax ID#
20. a. Wages/tips (before taxes) $
Weekly
Every 2 weeks
Twice a month
Monthly
Quarterly
Yearly ( Subtract any pre-tax deductions, such as nontaxable health insurance premiums.)
b. Income effective date
21. Average number of hours worked each WEEK
22. Is this job a sheltered workshop?
Yes
No
No. If yes, which months do you work in a calendar year?
23. Are you seasonally employed?
Yes
Jan.
Feb.
March
April
May
June
July
August
Sept.
Oct.
Nov.
Dec.
CURRENT JOB 2
| if you have more jobs and need more space, attach another sheet of paper.
24. Employer name and address
Federal Tax ID#
25. a. Wages/tips (before taxes) $
Weekly
Every 2 weeks
Twice a month
Monthly
Quarterly
Yearly ( Subtract any pre-tax deductions, such as nontaxable health insurance premiums.)
b. Income effective date
26. Average number of hours worked each WEEK
27. Is this job a sheltered workshop?
Yes
No
28. Are you seasonally employed?
Yes
No. If yes, which months do you work in a calendar year?
Jan.
Feb.
March
April
May
June
July
August
Sept.
Oct.
Nov.
Dec.
need more space, attach another sheet of paper.
SELF-EMPLOYMENT |
If self-employed, answer the following questions. If you
29. Are you self employed?
Yes
No
a. If yes, what type of work do you do?
b. On average, how much net income (profits after business expenses are paid) will you get from this self-employment each
month, or, how much will you lose from this self-employment each month? $__________/month profit OR $___________/
month loss?
c. How many hours do you work per week? _______
OTHER INCOME
30. Check all that apply, and give the amount and how often you get it. If you receive a one-time payment, please include the
month in which it was received. NOTE: You do not need to tell us about child support, nontaxable veteran’s payments,
Supplemental Security Income (SSI), or most workers’ compensation income.
Social security benefits $
How often/month received?
Unemployment $
How often/month received?
Retirement or pension $
How often/month received?
Source
Capital gains $
How often/month received?
Interest, dividends, and other Investment income $
How often/month received?
Royalty income $
How often/month received?
Net rental income:
On average, how much net income (profits after rental expenses are paid) will you get from this rental each month, or how
much will you lose from this rental each month? $
month profit or $
month loss
Net farming or fishing income $
How often/month received?
Alimony received $
How often/month received?
Other taxable income $
How often/month received?
Type
Page 5
ACA-3 (Rev. 07/17)
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