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New Income Verification Forms for Health Connector and MassHealth Applicants and Members

February 17, 2023

Members and applicants sometimes face difficulties providing the Health Connector and MassHealth proof of their reported income.

If a member experiences difficulties proving their income, there are income verification forms that can be used to prove ‘self-employment income’, ‘zero income’, or all ‘other income types’. These forms provide members and applicants with direction on how to report their income to respond successfully to their outstanding Request for Information (RFI) for income.

Always help members and applicants to understand what documentation is needed to verify their income. These income verification forms can be suggested to members and applicants if they are unable to provide any other acceptable proof. Below are scenarios to consider when someone can use these forms.

Self-Employment Income Form can be used when the applicant/member:

  • Has no formalized documentation (self-employment ledger, profit, or loss statement, or previous 1040) showing their current self-employment income
  • Does gig work (temporary short-term work like rideshare, food delivery, etc.) and does not have a bookkeeper
  • Has fluctuations in income that are not easily represented via current documentation

Attestation Form to Verify Income (used to verify all forms of income) can be used when:

  • Getting the needed documentation poses a safety risk
  • Accessing the documentation is impossible due to circumstances outside of the member’s control
  • Documentation sent is repeatedly rejected and the member has no other acceptable proof of income
  • Existing documentation is outdated or not representative of current income

Affidavit To Verify Zero Income can be used when:

  • An individual is currently not working and was asked to submit proof that they have no income, they may submit a signed written statement (also called an “affidavit”). The affidavit does not have to be notarized

These forms can be found on both the MassHealth and the Health Connector’s websites.


Certified Assisters, a related job aid titled Forms to Help Verify Income, is available in your Learning Management System, within the Assister Job Aids and Resources folder to download and review.