Proof of Income

Note: Self-attestation of income in a written statement signed under a penalty of perjury is accepted on a case-by-case basis.

Attestation of Income, No Documentation Available (PDF)

Submit a copy of one of the following documents.

Earned Income: Employer Wages

1. Pay stub. It must include:
   • Full name of the person or other identifying information to link to the person (e.g. SSN). Social Security card is not necessary.
   • Income amount.
   • Pay period or frequency of pay with the date of payment.
2. Most recently filed Federal Income Tax Form 1040, with any appropriate Schedules. It must include:
   • Full name of the person or other identifying information to link to the person (e.g. SSN).
   • Income amount.
   • Tax year.
3. Wages and tax statement (W-2 and/or 1099, including 1099 MISC, 1099G, 1099R, 1099SSA, 1099DIV, 1099SS, 1099INT).
   • It must contain the person’s first and last name, income amount, year, and employer name (if applicable).
4. Employer statement. The employer statement must:
   • Be on company letterhead or state the name of the company.
   • Be signed by the employer.
   • Be no older than 45 days from the date received by Covered California.
   • 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 pay.
     • The following two statements:
       • “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.”
     • Signature of the person writing the letter.
     • Printed name and job title or position of the person signing the letter.
     • A sample employer statement letter can be viewed here.
5. Foreign Income.
   • Pay stub, other documents.
   • Use dollar conversion based on date of document.

Earned Income: Self-Employment (includes farm income)

1. 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). It must contain:
   • The person’s first and last name and company name.
   • Dates covered and the net income from profit/loss.
2. Federal Tax Form 1040 with any appropriate Schedules.

Unearned Income

1. Annuity statements.
2. Statements of pension distribution from any government or private source.
3. Prizes, settlements, and awards, including alimony received and court-ordered awards letters. For divorce or separation documents dated after Dec. 31, 2018, alimony received is not counted as taxable income.
4. Proof of taxable gifts and contributions.
5. Proof of taxable scholarships or grants — for room and board only, not tuition, course-related fees, books or equipment. 
6. Proof of strike pay and other benefits from unions.
7. Sales receipts or other proof of money received from the sale, exchange or replacement of things the person owns.
8. Interests and dividends income statement.
9. Royalty or residual income statement or 1099-MISC.
10. Letter, deposit, or other proof of deferred compensation payments.
11. Social Security Administration Statements (Social Security Benefits Letter).
    • Retirement, Survivors Disability Insurance (RSDI), Social Security Retirement, Social Security Disability Insurance (SSDI).
    • It must contain first and last name, benefit amount, and frequency of pay.
12. Unemployment Benefits Letter.
    • It must contain the person’s first and last name, source/agency, weekly benefits amount, and duration (start and end date, if applicable).