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Get CA Sample Only: Self Affidavit of Income Letter 2008-2024

SAMPLE ONLY Self Affidavit of Income Letter Applicant s Name Address City State Zip Phone Number Today s Date Healthy Families/Medi-Cal for Families P. O. Box 138005 Sacramento CA 95813-8005 Dear Healthy Families and Medi-Cal for Families I am providing this affidavit to verify my income as I have no other income documentation available to me. I receive gross amount and the frequency of pay is weekly every two weeks twice a month or montly. I last received this amount on. I understand that this information is subject to verification by the State of California* I certify that the information presented in this letter is true and correct to the best of my knowledge and belief* Sincerely Signature of person receiving income This document must be hand written by the applicant. If the applicant cannot hand write they must put their mark X and include a printed name and signature of a witness. I receive gross amount and the frequency of pay is weekly every two weeks twice a month or montly. I last received this amount on. I understand that this information is subject to verification by the State of California* I certify that the information presented in this letter is true and correct to the best of my knowledge and belief* Sincerely Signature of person receiving income This document must be hand written by the applicant. I understand that this information is subject to verification by the State of California* I certify that the information presented in this letter is true and correct to the best of my knowledge and belief* Sincerely Signature of person receiving income This document must be hand written by the applicant. If the applicant cannot hand write they must put their mark X and include a printed name and signature of a witness. I receive gross amount and the frequency of pay is weekly every two weeks twice a month or montly. I last received this amount on. I understand that this information is subject to verification by the State of California* I certify that the information presented in this letter is true and correct to the best of my knowledge and belief* Sincerely Signature of person receiving income This document must be hand written by the applicant. If the applicant cannot hand write they must put their mark X and include a printed name and signature of a witness. .

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