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Get NY DOH-5018 2010-2024

NEW YORK STATE DEPARTMENT OF HEALTH Office of Health Insurance Programs Self-Declaration of Income Name App. Reg/Case Social Security Number XXX-XXAddress STREET 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 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. 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 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 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. 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 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. .

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