Proof of Household Income

Do you receive…

Then, send us one of the following documents:

Income from a job

·      Paycheck stubs showing employee information, pay date or pay period, and gross amount of pay, for the 4 weeks prior to the date listed on your notice.

·      1040 federal or state tax return from the previous year if representative of attested income.

·      Wages and tax statement (W-2 and/or 1099, including 1099 MISC, 1099G, 1099R, 1099SSA, 1099DIV, 1099SS, 1099INT) showing first/last name, income amount, year, and employer name (if applicable).

·      A signed earning statement from your employer showing first/last name, company contact information and gross pay information, signed by the employer and dated.

NOTE: If you are seasonally employed, any of the proofs above should include information about the duration of your employment.

Self-Employment Income

·       Self-Employment ledger documentation showing first/last name, company name, and income amount. If you’re submitting a self-employment ledger, include the dates covered by the ledger, and the net income from profit/loss (can be a Schedule C, the most recent quarterly or year-to-date profit and loss statement, or a self-employment ledger).

·       1040 SE with Schedule C, F, or SE (for self-employment income)

·       1065 Schedule K1 with Schedule E

·       Tax return

·       Bookkeeping records

·       Receipts for all allowable expenses

·       Signed time sheets and receipt of payroll, if you have employees

·       Most recent quarterly or year-to-date profit and loss statement

Social Security Disability or Retirement Benefits

·       Award letter/certificate dated within the last year

·       Annual benefit statement

·       Correspondence from the Social Security Administration with your award status (denied, award amount, still pending)

PA Unemployment Benefits

·       Award Letter/Certificate

·       Monthly benefits statement from the PA Department of Labor

·       Copy of Direct Payment Card with statement

·       Letter from the PA Department of Labor with reason for denial

Rental Income

·       Rent checks or rental payment receipts

·       Current lease

·       Signed letter from tenant with monthly rent amount

·       Filed tax return if representative of attested rental income

Proof of Household Income (continued)

Do you receive…

Then, send us one of the following documents:

Oher Sources of Income

·       Agricultural income certificate

·       Alimony received: court order stating alimony amount or signed statement from individual providing alimony with amount and frequency.

·       Annuity statement

·       Bank or investment fund statement

·       Cost of living adjustment letter and other benefit verification notices

·       Farm Income (See acceptable proof of “Self-Employment Income” listed above)

·       Foreign-Earned Income (See acceptable proof of “Income from a Job” listed above)

·       Gambling Income: Form W-2G

·       Interests and dividends income statement

·       Letter, deposit, or other proof of deferred compensation payments

·       Letter, deposit, or other proof of travel/business reimbursement pay

·       Loan statement showing loan proceeds

·       Military Leave and Earnings statement

·       Pay stub indicating sick pay

·       Pay stub indicating substitute/assistant pay

·       Pay stub indicating vacation pay

·       Prizes, settlements, and awards, including court-ordered awards letter

·       Proof of bonus/incentive payments

·       Proof of gifts and contributions

·       Proof of inheritances in cash or property

·       Proof of residuals

·       Proof of severance pay

·       Proof of strike pay and other benefits from unions

·       Rental, real estate, royalties, partnerships, S-Corps, trusts: rent checks or rental payment receipts, current lease, signed letter from tenant with monthly rental amount, royalty checks, or financial record of payment from trusts

·       Royalty income statement or 1099-MISC

·       Sales receipts or other proof of money received from the sale, exchange, or replacement of things you own

·       Statement of pension distribution from any government or private source

·       Worker’s compensation letter

Proof of Immigration Status

If you are…

Then, send us one of the following documents:

An Immigrant Non-Citizen or a Non-Immigrant Visa Holder

·       I-551 resident alien card (green card)

·       Temporary I-551 resident alien card (temporary green card)

·        I-766 employment authorization card

·       Proof of current visa status (for example, a stamp in your passport, or an approval letter from United States Citizenship and Immigration Services (USCIS))

·       Proof of resolution in immigration court (all pages)

·       Notice of hearing from the Executive Office for Immigration Review

·       “Documents (all pages) you provided to or received from USCIS or Immigration and Customs Enforcement (ICE):

o   ICE, such as

o   Confirmation that your application for an immigration status was received

o   Letters to or from USCIS

o   I-797 USCIS Notice of Action

o   Order of Supervision from ICE

o   Other documents to or from USCIS or ICE that show your current status”

·       I-94 arrival/departure record

·       An approved immediate relative I-130 petition

·       Refugee Travel Document (I-571)

·       Re-entry Permit (I-327)

·       SEVIS ID (I-20 or DS 2019) (all pages)

·       Office of Refugee Resettlement (ORR) or Office on Trafficking In Persons (OTIP)

·       Certification or eligibility letter (all pages)

·       “Immigration or other official document showing grant of:

o   Withholding of Removal

o   Asylum

o   Cancellation of Removal

o   Administrative Closure

o   Administrative Order Staying Removal

o   Order of Supervision

o   Proof that you lived continuously in the U.S. before 1972 (for example, your lease agreement or proof of employment)”

Proof of Immigration Status (continued)

If you are…

Then, send us one of the following documents:

A Battered Immigrant Non-Citizen

·       Proof of your immigration status

·       Proof/evidence of the harm or abuse (if your immigration document isn’t based on being battered)

·       Proof of your relationship with the abuser (if your immigration document isn’t based on being battered)

·       Proof that you no longer reside with the abuser

·      Documents (all pages) that prove your immigration status could include:

o   I-797 Notice of Action indicating that the alien has an approved I-360 self-petition

o   I-797 Notice of Action indicating that the alien has a pending I-360 self-petition that has established a prima facie case

o   Order from the Executive Office for Immigration Review (“EOIR”) granting or finding a prima facie case for granting, suspension of deportation or cancellation of removal

o   I-797 Notice of Action indicating that the alien has a pending I-360 self-petition AND credible evidence of battery or abuse

o   I-797 Notice of Action indicating the alien is the beneficiary of a pending or approved I-130 petition and credible evidence of battery and/or abuse

o   I-94 coded, K3, K4, V1, V2, V3, and credible evidence of battery or abuse

o   Any other USCIS document indicating the alien has a K or V visa and a pending or approved I-130 petition with credible evidence of battery or abuse

o   I-94 or a Foreign passport annotated CR1, CR2, CR6, CR7 with credible evidence of battery or abuse

o   I-766 Employment Authorization Document annotated A9, A15 or C10 with credible evidence of battery or abuse

·       Documents (all pages) that show proof of harm or abuse could include:

o   Reports from court, police, judges, medical evidence from a medical professional

o   Clergy, or mental health personnel

o   Affidavits from others or other evidence that could support your claim such as proof of a domestic violence conviction or proof of seeking safe-haven in a battered shelter

o   Documents that prove your relationship with the abuser could include:

§  Marriage certificate

§  Birth Certificate (for child of an abuser)

Proof of Citizenship

If you are…

Then, send us one of the following documents:

A U.S. Citizen/U.S. National

·       U.S. passport

·       Certificate of Naturalization (N-550/N-570)

·       Certificate of Citizenship (N-560/N-561)

·       State-issued enhanced driver's license (available in Michigan, New York, Vermont, and Washington)

·       "Document from federally recognized Indian tribe that includes your name and the name of the federally recognized Indian tribe that issued the document, and shows your membership, enrollment, or affiliation with the tribe. Documents you can provide include:

o   A tribal enrollment card

o   A Certificate of Degree of Indian Blood

o   A tribal census document

o   Documents on tribal letterhead signed by a tribal official”

Or… you can provide two of the following documents

·       U.S. public birth certificate

·       Consular Report of Birth Abroad (FS-240, CRBA)

·       Certification of Report of Birth (DS-1350)

·       Certification of Birth Abroad (FS-545)

·       U.S. Citizen Identification Card (I-197 or the prior version I-179)

·       Northern Mariana Card (I-873)

·       Final adoption decree showing the person’s name and U.S. place of birth

·       U.S. Civil Service Employment Record showing employment before June 1, 1976

·       Military record showing a U.S. place of birth

·       U.S. medical record from a clinic, hospital, physician, midwife, or institution showing a U.S. place of birth

·       U.S. life, health, or other insurance record showing U.S. place of birth

·       Religious record showing U.S. place of birth recorded in the U.S.

·       School record showing the child’s name and U.S. place of birth

·       Federal or state census record showing U.S. citizenship or U.S. place of birth

·       Documentation of a foreign-born adopted child who received automatic U.S. citizenship (IR3 or IH3)

·       Driver's license issued by a state or territory or ID card issued by the federal, state, or local government

·       School identification card

Proof of Citizenship (continued)

If you are…

Then, send us one of the following documents:

A U.S. Citizen/U.S. National

·       U.S. military card or draft record or military dependent’s identification card

·       U.S. Coast Guard Merchant Mariner card

·       Voter Registration Card

·       A clinic, doctor, hospital, or school record, including preschool or day care records (for children under 19 years old)

·       2 documents containing consistent information that proves your identity, like employer IDs, high school and college diplomas, marriage certificates, divorce decrees, property deeds, or titles

Social Security Number (SSN)

Do you need to verify…

Then, send us one of the following documents:

Social Security Number (SSN)

·       Social Security card

·       1040 Tax Return (federal or state versions acceptable)

·       W2 and/or 1099s (includes 1099 MISC, 1099G, 1099R, 1099SSA, 1099DIV, 1099S, 1099INT)

·       W4 Withholding Allowance Certificate (federal or state versions acceptable)

·       1095 (includes 1095A, 1095B, 1095C)

·       Pay stub documentation

·       Social Security Administration documentation (includes 4029)

·       Military record

·       U.S. Military ID card

·       Military dependent’s ID card

·       Unemployment Benefits (Unemployment Benefits Letter)

·       Court Order Granting a Name Change, that must have your original first and last name, new first and last name, and SSN

·       Divorce decree

No Minimal Essential Coverage

Do you need to verify…

Then, send us one of the following documents:

No minimal essential job-based coverage

·       Completed Employer Coverage Tool (PDF) and a cover letter signed by the employer

·       “Letter or other documentation from an employer or other documentation with this information:

o   Statement that the employer doesn’t currently offer you (or your family member) coverage

o   Statement that the employer doesn’t provide coverage that isn’t qualifying health coverage

o   Statement showing the cost of your share of the premium for the lowest-cost self-only plan that meets the minimum value standard (factoring in wellness incentives), if offered”

·       Health insurance letter that contains confirmation of health coverage and expiration dates for coverage received outside of the Marketplace

No qualifying health coverage through Medicaid or CHIP

·       Letter or statement from a Medicaid or CHIP agency that shows that you or your family members aren’t enrolled in or eligible for Medicaid or CHIP

·       Letter or statement from a Medicaid agency showing that you or a family member are enrolled in a Medicaid program that’s not considered qualifying health coverage

·       "You can find more detailed information about Medicaid programs that don’t provide qualifying coverage. If you send document(s) verifying enrollment in one of these programs, you may be able to continue your financial help for your Marketplace coverage:

o   Medicaid coverage only for pregnancy-related services

o   Medicaid coverage only for family planning services

o   Medicaid coverage only for tuberculosis coverage

o   Medicaid coverage only for emergency treatment

o   Medicaid Demonstration Projects that cover a limited range of benefits

o   Medicaid coverage for “medically needy” individuals whose income is too high for traditional Medicaid and cover a limited range of benefits. These programs are sometimes known as “Share of Cost” or “Spend Down” programs."

·       "A letter describing your recent health coverage including:

o   The name of the Medicaid/CHIP program you were enrolled in and when your coverage ended, or

o   That you were never enrolled in Medicaid/CHIP coverage, or

o   The name of the Medicaid/CHIP program with limited benefits that you’re enrolled in that would still allow you to enroll in the Marketplace with help paying for coverage"

No Minimal Essential Coverage (continued)

Do you need to verify…

Then, send us one of the following documents:

No qualifying health coverage through Medicare

·       “Letter or statement from Medicare or the Social Security Administration stating that you or your family members are:

o   Not eligible for or enrolled in premium-free Medicare Part A.

o   Eligible for (but not enrolled in) Part A coverage that requires premium payments. Important: A Social Security document that shows you don’t pay a premium for “Medical Insurance” refers to Part B. It’s not acceptable for verifying eligibility for Part A.

o   No longer eligible for Social Security Disability Insurance (SSDI) benefits, and your coverage has ended or will end in the next 90 days.”

No qualifying health coverage through TRICARE

·       Letter or statement from TRICARE that shows the expiration or un-enrollment date of previous health coverage

·       Letter or statement from TRICARE that confirms ineligibility for health coverage

·       Letter, statement, or other document indicating a life change event (like divorce) that would make you or a family member ineligible for TRICARE coverage

·       "Letter or statement from TRICARE or other government agency showing that you or a family member are enrolled in a TRICARE program that’s not considered qualifying health coverage. If you send document(s) verifying enrollment in one of these programs, you may be able to continue your Marketplace coverage with help paying for coverage:

o   TRICARE Plus

o   Direct care

o   Line-of-duty care

o   Transitional care for service-related conditions

o   TRICARE coverage limited to space-available care in a facility of the uniformed services for individuals excluded from TRICARE coverage for care from private sector providers."

No qualifying health coverage through Veterans Affairs

·       Letter from the VA that shows the expiration date of previous health coverage

No qualifying health coverage through the Peace Corps

·       Letter from the Peace Corps with the expiration date for any previous health coverage or a letter showing that you never had this type of coverage

Proof of American Indian or Alaska Native Status

Do you need to verify…

Then, send us one of the following documents:

American Indian or Alaska Native Status

·       Tribal Enrollment/Membership card from a federally recognized tribe

·       Document issued by Bureau of Indian Affairs (BIA) recognizing you as American Indian/Alaska Native

·       Authentic document from a federally recognized tribe declaring your membership

·       Certificate of Degree of Indian Blood

·       Certificate of Indian status card

·       I-872 American Indian Card (Texas and Oklahoma Kickapoo American and Mexican members)

·       Document issued by Indian Health Service (IHS) showing that you were/are eligible for IHS services as an American Indian/Alaska Native

·       U.S. American Indian/Alaska Native tribal enrollment or shareholder documentation

·       Letter from the Marketplace granting a tribal exemption based on tribal membership or Alaska Native shareholder status

Other

Do you need to verify…

Then, send us one of the following documents:

State Residency

·       Copy of deed and record of most recent mortgage payment (if mortgage is paid in full, provide a copy of property tax bill from the most recent year)

·       Copy of lease and record of most recent rent payment

·       Mortgage deed showing primary residence

·       Nursery school or daycare records (if school is private, additional documentation may be requested)

·       Current utility bill or work order dated within the past 60 days

·       Statement from a homeless shelter

·       School records (if school is private, additional documentation may be requested)

·       Section 8 agreement

·       Homeowner’s insurance agreement

·       Proof of enrollment of custodial dependent in public school

Other (continued)

Do you need to verify…

Then, send us one of the following documents:

Non -incarceration

·       Official release papers from the institution or Department of Corrections

·       Parole papers

·       Unexpired state ID, driver’s license, work ID, or passport

·       Pay stubs

·       Federal, state, or local benefit letter

·       Clinic, doctor, or hospital records for services provided

·       Medical claim explanation of benefits provided

·       School record/schedule showing enrollment (like for college students)