Attestation for Frequently Changing Monthly Income
Instruction: Use this Affidavit if you or a household member has income that changes from
month to month, for example, due to seasonal or contractual work, and you do not have any
other evidence to provide. Other evidence could include a signed contract for seasonal
employment, a history of predictable income fluctuations, notice of employment termination or
other indication of future income change, or the prior year’s tax return if it reflects seasonal or
other irregular employment.
APPLICATION #______________________ SSN# or TIN# _________________
I, __________________________________(name), attest and affirm the following:
1. My household income changes from month to month because:
______________________________________________________________________
______________________________________________________________________
2. Monthly income is expected to be the following for each of the next 12 months:
Current month: __________ Month 2: __________ Month 3: __________
Month 4: __________ Month 5: __________ Month 6: __________
Month 7: __________ Month 8: __________ Month 9: __________
Month 10: __________ Month 11: __________ Month 12: __________
3. There is no other evidence of the changes in income from month to month because:
_____________________________________________________________________
______________________________________________________________________
4. I understand that if I am determined eligible for a Qualified Health Plan that I must report any
changes (including income, address, household members and pregnancy status) within 30 days
to GetCoveredNJ because it may affect the amount of premium assistance (or tax credits) or the
level of cost-sharing reduction for which I may qualify, and I can do this by logging into my
online account at GetCovered.nj.gov or by calling the Call Center at 1-833-677-1010. 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.
5. I declare under penalty of perjury and hereby certify that the foregoing statements made by
me are true and correct. I am aware that if any of the foregoing statements made by me are
willfully false, I am subject to punishment.
______________________________________ _______________________
Signature Date
