DATE: _______________________ APPLICATION ID: ______________________________
NAME: ________________________________ SSN OR TAX ID: ______________________
I _____________________________________, swear or affirm that I currently do not have any
earned or unearned income of any kind. This includes, but is not limited to, income from wages
or self-employment, income from rental property or investments, unemployment, retirement or
social security benefits, alimony, or IRA or pension distributions.
I have no income for the following reason(s). Select all that apply:
_____ I have no job and have no unemployment benefits.
_____ I have lost other sources of income (for example: benefits ended, loss of investment
income, loss of alimony payments).
_____ I have a medical condition that prevents me from working.
_____ I am incarcerated.
_____ I (or my dependent) have never worked.
I hereby certify that the statements provided in this affidavit (explanation) of no income
are true and accurate to the best of my knowledge.
I understand if I am determined eligible for Medicaid or a Qualified Health Plan I must report
any and all changes (including changes in income, address, household members or pregnancy
status) within 10 days to the Maryland Health Connection or my local health department or
social services or I can do this by logging into my online account at
_____________________________________________ _______________________
Rev. 11122020
I am unable to sign and scan due to the coronavirus state of emergency.
click to sign
click to edit