Covered California
P.O. Box 989725
West Sacramento, CA 95798-9725
Case Number:
Attestation of Income, No Documentation Available
I,
(last name)
attest that my household’s projected annual income for the benefit year in which I will receive
financial assistance for my health plan is $
(annual income)
I acknowledge that the information provided on this form will only be used for purposes of
eligibility determination for financial assistance. Covered California will keep this
information private, as required by federal and California law.
I understand that I must report income changes to Covered California within 30 days of the
change because it may affect the amount of premium assistance (or tax credits) or the level
of cost-sharing reduction for which I may qualify.
I understand that if I receive too much premium assistance (or tax credits) during the
benefit year, I will have to pay some or all of the excess premium assistance back to the
Internal Revenue Service (IRS) when I file my federal income tax return for the benefit year.
I declare under the penalty of perjury, under the laws of the state of California, that what I
stated above is true and correct.
Applicant’s Signature: ___________________________ Date:
MM DD
YYYY
Send your form in one of the following ways:
Fax
(888) 329-3700
Mail
Covered California
P.O. Box 989725
West Sacramento, CA 95798-9725
Your destination for affordable
health insurance, including Medi-Cal
(first name)
(middle name)
/
/
Electronic Submission
For faster processing upload
this document directly to your
online account at
CoveredCA.com
