Proof of Income

Before You Submit

Your household income helps determine whether you qualify for Medi-Cal or a Covered California plan and how much financial help you'd get.

Covered California compares the income you reported with records from government sources, like the IRS and Social Security Administration. If the information doesn’t match, we may ask you to confirm your income by submitting a document.

In most cases, you only need to submit one document. Choose from the list that matches your income type.

Employer Wages

This is the income you earn through a job or other work. Submit a copy of one of the following documents.

Pay Stub

Your pay stub must include:

• Your full name or other identifying information (for example, a Social Security number)
• Income amount
• Pay period or frequency of pay with the date of payment

Federal Income Tax Form 1040

Your most recently filed Form 1040, with any appropriate schedules, must include:

• Your full name or other identifying information (for example, a Social Security number)
• Income amount
• Tax year

Wage or Income Tax Statement

This includes W-2, 1099-MISC, 1099G, 1099R, 1099SSA, 1099DIV, 1099SS, 1099INT, 1099NEC, or other forms displaying your income and taxes. The document must include your first and last name, income amount, the year and employer name if applicable.

Employer Statement

An employer statement may be used if no other formal documentation, such as a pay stub or tax return, is available. For reference, download a sample employer statement (PDF).

Employer Statement Requirements

Format requirements. The statement must:

• Be on company letterhead or state the name of the company
• Be signed by the employer
• Be dated within 45 days of submission to Covered California

Required content. The statement must include:

• Name of employer or company
• Name of person writing the letter
• Employer or company address
• Employer or company telephone number
• Date of the letter
• Start date of employment (and end date, if no longer employed)
• The signature, printed name and job title or position of the person writing the letter

Required certification statements. The statement must include both of the following:

• "I certify that [first and last name of person employed or receiving income] is/was an employee of [name of company]. [Employee name]'s gross income for this pay period is/was $__________ and frequency of pay is [weekly, every two weeks, twice a month, or monthly]. This letter does not guarantee employment or wages."
• "The information provided above is true and correct to the best of my knowledge."

Foreign Income

You may use a pay stub or other documents. Use dollar conversion based on the date of the document.

Self-Employment Income (Including Farm Income)

Submit a copy of one of the following documents.

Profit and Loss Statement or Ledger

This includes the most recent quarterly or year-to-date profit and loss statement or a self-employment ledger. It must contain:

• Your first and last name and company name
• Dates covered
• Net income from profit or loss

Federal Tax Form 1040 With Schedule C

Your Form 1040 with any appropriate schedules is also acceptable.

Unearned Income

This is money you earn through investments, disbursements and other non-work activities. Submit a copy of one of the following documents:

• Annuity statements
• Statements of pension distribution from any government or private source
• Prizes, settlements and awards, including alimony received and court-ordered awards letters — Note: For divorce or separation documents dated after Dec. 31, 2018, alimony received is not counted as taxable income
• Proof of taxable gifts and contributions
• Proof of taxable scholarships or grants — for room and board only, not tuition, course-related fees, books or equipment
• Proof of strike pay and other benefits from unions
• Sales receipts or other proof of money received from the sale, exchange or replacement of things you own
• Interest and dividends income statement
• Royalty or residual income statement or 1099-MISC
• Letter, deposit or other proof of deferred compensation payments

Social Security Administration Statements

This includes Social Security Benefits Letters for Retirement, Survivors Disability Insurance (RSDI), Social Security Retirement and Social Security Disability Insurance (SSDI). The document must contain your first and last name, benefit amount and frequency of pay.

Unemployment Benefits Letter

The letter must contain your first and last name, source or agency, weekly benefit amount and duration, including start and end date if applicable.

If You Don’t Have Income Documents

If you don’t have any of the above documents, you may also be able to provide a written statement confirming your income.

You can download the Attestation of Income, No Documentation Available (PDF) form and submit it by uploading it to your online account, by fax or by mail. This form is accepted on a case-by-case basis and is signed under a penalty of perjury.

Attestation forms are valid only for the benefit year for which coverage is requested. They must be renewed each benefit year.