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Documents needed to confirm your eligibility for a Qualified Health Plan (QHP)

The links below highlight the documents needed to support your application and confirm eligibility:

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Qualifying
Proof

Proof of Income

To verify your income, send us any of the following documents:

Proof of Income

Pay stub. Sample Pay Stub can be viewed here. It must include:
  • Your full name (first name, last name, middle name or middle initial, if available) or other identifying information (i.e. your Social Security number (SSN)).
  • Date of the pay stub – To verify annual income, the pay stub you submit must be dated within six (6) months of the application date.
  • Pay period – The pay stub pay period must be within six (6) months of the date Access Health CT receives the application.
  • Duration of pay period – The total amount of time that pay stubs are meant to capture for verification purposes is one month of pay or four (4) weeks of time. Pay stubs may show different periods of work time, but all submitted pay stubs need to show a total duration of a month. It is recommended that you submit consecutive pay stubs to satisfy the verification requirement.
  • Company name – The pay stubs you submit should all be from the same company. You may submit pay stubs from different companies, but they need to cover a distinct monthly period, as opposed to being added together as a single income for the same monthly period.
  • Income amount – The gross income amount from all submitted pay stubs is verified against the annual income reported in the application.
U.S. Individual Income Tax Return: Form 1040, 1040NR, 1040A, 1040ES, 1040NR-EZ 1040EZ, with original 1040 from previous year, with any appropriate Schedules (i.e. Schedule C, Schedule F, Schedule SE, Schedule E). It must include:
  • Your full name (first name, last name, middle name or middle initial if available).
  • Your SSN; if filed jointly, submit SSN of your spouse as well.
  • Annual income amount.
  • Tax year – tax returns must be from the previous year.
Sample 1040 can be viewed here.

Sample 2017 Schedule C can be viewed here.

Sample 2017 Schedule E can be viewed here.
Wage and Tax Statement (W-2 and/or 1099, including 1099 MISC, 1099G, 1099R, 1099SSA, 1099DIV, 1099B, 1099INT). It must include:
  • Your full name (first name, last name, middle name or middle initial, if available.
  • Gross annual income amount.
  • Tax year – must be from the previous calendar year.
  • Employer name (if applicable).
Sample W-2 can be viewed here.

Sample 1099-MISC can be viewed here.

Proof of Income 2

Employer Statement cannot be used for the self-employment income. It must:
  • Be on company letterhead or state the name of the company.
  • Be signed by the employer.
  • Be no older than six (6) months of the application date.
  • Include the following information:
    • Name of employer or company.
    • Name of person writing the letter.
    • Employer or company address.
    • Employer or company telephone number.
    • Date of the letter.
    • The start date and, if applicable, the end date of the employee’s employment or period of pay (i.e. weekly, bi-weekly, monthly, or annually).
    • The total amount earned during the employee’s employment or applicable period of pay.
Sample Employer Statement Letter can be viewed here.
Self-employment profit and loss statement or ledger documentation (the most recent quarterly or year-to-date profit and loss statement, or a self-employment ledger) must be no older than twelve (12) months of the application date. It must contain:
  • Your first and last name and company name.
  • Dates covered and the net income from profit/loss.
A sample Income Statement/Profit and Loss Statement can be viewed here.
NOTE: This is a sample of profit and loss statement. Not all the fields in this template are mandatory. You may consider completing the fields that are applicable to your business.

Sample 2017 Schedule C can be viewed here.
Below are other documents that you can use to verify your annual income. Dates of documents must be no older than one (1) year of the application date.
  • Annuity statements
  • Statements of pension distribution from any government or private source.
  • Prizes, settlements, and awards, including alimony received and court-ordered awards letters.
  • Proof of taxable gifts and contributions.
  • Proof of taxable scholarships or grants.
  • Proof of inheritances in cash or property.
  • 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 Form 1099-MISC.
  • Letter, deposit, or other proof of deferred compensation payments.
  • Social Security Administration Statements (Social Security Benefits Letter).
  • Retirement, Survivors Disability Insurance (RSDI), Social Security Retirement, Social Security Disability Insurance (SSDI).
    • It must contain your first and last name, benefit amount, and frequency of pay.
  • Unemployment Benefits Letter
    • It must contain your first and last name, source agency, weekly benefits amount, and duration (start and end date), if applicable.
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Complete on your computer or mobile device.

How to Submit Documents

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Sample Pay Stub
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Sample 1040
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Sample 2017 Schedule C
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Sample 2017 Schedule E
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Sample W-2
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Sample 1099-MISC
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Sample Employer Statement Letter
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Sample Income Statement
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Sample Employer Statement SP
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Sample Attestation of Non Income Form SP
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Sample Affidavit of Identity Form Individual SP
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Sample Affidavit of Identity Form Child SP
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Sample W-2 SP
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Sample 2017 Schedule E SP
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Sample 2017 Schedule C SP
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Sample 1040 SP
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