[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-285610-105":3,"detail-sidebar-cat-1-en-105":81,"doc-detail-285610-en":126},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":74,"head_meta":76,"extra_data":78,"updated_unix":80},105,"en","new-york-state-department-of-health-self-declaration-of-income-form","New York State Department of Health - Self-Declaration of Income Form","","This document is an official Self-Declaration of Income form issued by the New York State Department of Health, specifically under the Office of Health Insurance Programs. It serves as a formal mechanism for applicants who lack standard income documentation, such as pay stubs or employer letters, to attest to their cash income. The form requires the applicant to provide detailed personal information, certify the truthfulness of their reported income, and acknowledge the legal consequences of intentional misrepresentation. Additionally, it includes a mandatory certification section for Facilitated Enrollers to confirm they have exhausted other documentation methods and have accurately recorded the applicant's information without modification. This standardized template ensures compliance with state regulations for public health insurance eligibility determinations.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/new-york-state-department-of-health-self-declaration-of-income-form/285610/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/new-york-state-department-of-health-self-declaration-of-income-form/285610.png","ImageObject",442,249,{"name":42,"@type":43},"Elsa","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-31","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",16,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"Who should complete this form?","Question",{"text":63,"@type":64},"This form is intended for applicants who receive cash income and have no other standard way to document their earnings, such as through pay checks, pay stubs, or employer letters.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"What are the consequences of providing false information?",{"text":68,"@type":64},"Intentionally misrepresenting income may result in the requirement to repay benefits received and potential prosecution under New York State law.",{"name":70,"@type":61,"acceptedAnswer":71},"What is the role of the Facilitated Enroller?",{"text":72,"@type":64},"The Facilitated Enroller must certify that they have attempted to obtain other sources of documentation, accurately recorded the applicant's reported information without modification, and acknowledge the legal consequences of falsifying data.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},285610,1789630111,{"code":4,"msg":82,"data":83},"success",[84,89,94,99,104,108,112,117,122],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":90,"doc_module":22,"doc_module_name":25,"category_name":91,"show_sort_weight":92,"slug":93},12,"Resumes",80,"resumes",{"id":95,"doc_module":22,"doc_module_name":25,"category_name":96,"show_sort_weight":97,"slug":98},14,"Invoices",70,"invoices",{"id":100,"doc_module":22,"doc_module_name":25,"category_name":101,"show_sort_weight":102,"slug":103},15,"Posters",60,"posters",{"id":55,"doc_module":22,"doc_module_name":25,"category_name":105,"show_sort_weight":106,"slug":107},"Social Media",50,"social-media",{"id":109,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":110,"slug":111},17,40,"forms",{"id":113,"doc_module":22,"doc_module_name":25,"category_name":114,"show_sort_weight":115,"slug":116},18,"Letters",30,"letters",{"id":118,"doc_module":22,"doc_module_name":25,"category_name":119,"show_sort_weight":120,"slug":121},21,"Paper Templates",5,"papers-templates",{"id":123,"doc_module":22,"doc_module_name":25,"category_name":124,"show_sort_weight":4,"slug":125},158,"General","general-158",{"code":4,"msg":82,"data":127},{"doc_id":79,"user_id":128,"nickname":42,"user_avatar":129,"doc_module":22,"category_id":109,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":22,"language":135,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":12,"update_tm":80,"read_time":4},137455077381,"https://ap-avatar.wpscdn.com/davatar_994ba38a5ba835b3df7d355c54d3ed8d","Attachment V  \nNEW YORK STATE DEPARTMENT OF HEALTH  \nOffice of Health Insurance Programs Self-Declaration of Income  \nName:   App Reg./Case \\# :    \nSocial Security Number:    \nAddress:   City:   State:   Zip Code:    \nComplete 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.  \n I get paid in cash.  \n I do not get pay checks.  \n I do not get pay stubs.  \n I cannot get a letter from my employer. Explain why:    \nMy cash income is $  How often (weekly, monthly etc. )    \nCurrent Employer:    \nApplicants/Recipients must read the following and sign below  \nI 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.  \nSignature of Applicant:   Date:    \nFacilitated Enrollers must read the following and sign below  \nI 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.  \nName:   Signature:   Date:","cbCaipBf9XkcVGiy","https://ap.wps.com/l/cbCaipBf9XkcVGiy","pdf",20476,"English","# Self-Declaration of Income Form\n## Applicant Information\n## Income Statement and Certification\n## Facilitated Enroller Certification","[{\"question\":\"Who should complete this form?\",\"answer\":\"This form is intended for applicants who receive cash income and have no other standard way to document their earnings, such as through pay checks, pay stubs, or employer letters.\"},{\"question\":\"What are the consequences of providing false information?\",\"answer\":\"Intentionally misrepresenting income may result in the requirement to repay benefits received and potential prosecution under New York State law.\"},{\"question\":\"What is the role of the Facilitated Enroller?\",\"answer\":\"The Facilitated Enroller must certify that they have attempted to obtain other sources of documentation, accurately recorded the applicant's reported information without modification, and acknowledge the legal consequences of falsifying data.\"}]","New York State Department of Health - Self-Declaration of Income Form | PDF"]