This article has a list of documents that can be used to verify your eligibility or other information. You can also see general information about verifications and instructions for uploading documents. If you still have questions, find help on the Access Health CT website or call us at 1-855-805-4325 (TTY 1-855-789-2428 or contact us at 1-855-805-4325 with a relay operator). 

 If you received a letter from us asking you to submit documents to confirm your eligibility for healthcare coverage, follow the steps described below. Even if you have enrolled and started using your plan, you may lose your coverage or financial help if we don't receive those documents from you by the deadline indicated in the letter. 

The letter you receive will tell you what kind of information we need, such as:

• Proof of Income
• Proof of Identity
• Proof of U.S. Citizenship or U.S. National Status
• Proof of Lawful Presence/Immigration Status
• Proof of Eligibility for Financial Help
• Proof of Qualifying Life Event for Special Enrollment

Please see below for more information regarding what documents you can provide for each category.

Income

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

Employer Wages (Earned Income)

Pay stub 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

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 previous year. 

View Sample 1040 [PDF]

View Sample Schedule C [PDF]

View Sample Schedule E [PDF]

Wage and Tax Statement

 

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).

View Sample W-2 [PDF]

View Sample 1099-MISC [PDF]

Employer Statement

 

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.

View Sample Employer Statement Letter [PDF]

Self-employment income

 

Self-employment income (includes farm income)

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.

View Sample Income Statement/Profit and Loss Statement [JPG]

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.

View Sample Schedule C [PDF]

Other

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.

Download a fillable Attestation of Non-Income Form [PDF] 

Identity

All documents that you submit for verification of identity must match your name and date of birth, and if applicable, the name and birth date of each member of your household included on the application. 

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

• Voter Registration Card
• Identification card issued by the federal, state, or local government
  • Identification card issued by the federal, state, or local government that contains a photograph. 
  • View Sample Hartford ID card [PNG]
• U.S. military card, draft record, or military dependent's identification card
• U.S. or foreign passport, U.S. passport card, or identification card issued by a foreign embassy or consulate
  • U.S. or foreign passport, U.S. passport card (expired passport may be used), or identification card issued by a foreign embassy or consulate that contains a photograph. 
• Certificate of Naturalization (Form N-550 or N-570) or Certificate of U.S. Citizenship (Form N-560 or N-561)
• Permanent Resident Card or Alien Registration Receipt Card (Form I-551)
  • View Sample Green Card [JPG]
• Employment Authorization Document
  • Deferred Action for Childhood Arrivals (DACA) is not an eligible immigration status for applying through the Exchange. 
  • View Sample Employment Authorization Card (EAD) on the USCIS website
• Native American Tribal Document
  • Native American tribal document with photograph. 
• For children under the age of 16
  • A clinic, doctor, or school record. 
  • In the absence of the aforementioned records, a written statement signed under penalty of perjury by the parents or guardian stating date and place of birth. An Affidavit of Identity Form (for each child on the application). Download an Affidavit of Identity Form [PDF], which you can complete on your computer or mobile device. Affidavits must be signed in the presence of a Notary Public or Commissioner of the Superior Court.
• Affidavit of Identity (Individual/Applicant)
  • Affidavits must be signed in the presence of a Notary Public or Commissioner of the Superior Court. 
  • Download an Affidavit of Identity Form [PDF], which you can complete on your computer or mobile device. 
• U.S. Coast Guard Merchant Mariner card
• Finding of identity from a federal agency or state government agency
  • Finding of identity from a federal agency or state government agency including but not limited to public assistance, law enforcement, internal revenue or tax bureau, or corrections agency, if the agency has verified and certified your identity. 
• Driver's License issued by a Canadian government authority
  • View Sample Canadian Driver's License [JPG] 
• Driver's License issued by a state or territory
  • Driver's License issued by a state or territory showing either a photograph of you or other identifying information such as your name, age, sex, race, height, weight, or eye color. 
  • View Sample CT Driver's License [JPG] 

U.S. Citizenship or U.S. National Status

All documents that you submit for verification of citizenship must match your name and birth date and, if applicable, the name and birth date of each member of your household included on the application.

To verify your citizenship:

• Review the two lists below; you must provide one document from each list. Choose one document in List A and one document in List B to prove your citizenship.

List A

• U.S. Passport or U.S. Passport Card, current or expired (issued without limitation). 
• U.S. Birth Certificate
  • View Sample U.S. Birth Certificate [JPG] 
• Certification of Report of Birth
• Certificate of U.S. Citizenship
  • Form N-560
  • Form N-561
• Certificate of Naturalization
  • Form N-550
  • Form N-570
• American Indian or Alaska Native Tribe Documents 
  • Documentary evidence issued by a federally recognized American Indian or Alaska Native tribe. Documents must identify the individual by name and confirm the individual's membership, enrollment, or affiliation with a tribe. Acceptable documents include but are not limited to: 
    • Tribal enrollment card
    • Certificate of Degree of Indian Blood
    • Tribal census document
    • Documents on Tribal letterhead, issued under the signature of the appropriate Tribal office
• Consular Report or Certificate of Child Born Abroad
  • Department of State Form FS-545
  • Department of State Form FS-240
  • Department of State Form DS-1350
• U.S. Citizen Identification Card 
  • Form I-197 or the prior version I-179
• Federal or State census record showing U.S. Citizenship or U.S. place of birth
• Northern Marianas Identification Card
• Adoption Decree
  • A final adoption decree showing the child's name and U.S. place of birth; or 
  • If the adoption is not finalized, a statement from a state-approved adoption agency that shows the child's name, U.S. place of birth, and birth date or age (the adoption agency must state in the certification that the source of the place of birth information is an original birth certificate). 
• Documentation that a child meets the requirements of section 101 of the Child Citizenship Act of 2000 (8 U.S.C 1431)
• U.S. Military records showing a U.S. place of birth
• Evidence of U.S. Civil Service employment before June 1, 1976
   

List B

Document from List B must include a photograph or other information such as a name, race, height, weight, eye color or address.

• Driver's License
  • Driver's license issued by a state or territory or ID card issued by the federal, state, or local government.
• School identification card 
• U.S. Military card or draft record or military dependent's identification card
• U.S. Coast Guard Merchant Mariner card 
• Voter Registration card
• Medical/Care Document
  • A clinic, doctor, hospital, or school record, including preschool or day care records (for children under 19 years old) 
• Matching Documents
  • 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
     

Lawful Presence/Immigration Status

In general, all of these documents will follow the same rules for document acceptability used for verification of the household's lawful presence. This means a submitted document must have the following to be accepted: 

• Your full name (first name, last name, and middle name or middle initial if available). 
• An expiration date that has not passed. 
• An alien number that is the same on the application as it is on the provided immigration document. 

To verify your lawful presence or immigration status, send us any of the following documents:  

• Permanent Resident Card ("Green Card", I-551)
  • View Sample Permanent Resident Card [JPG] 
• Temporary I-551 Stamp (on passport or I-94, I-94A)
• Immigrant Visa (with temporary I-551 language) 
  • View Sample Immigrant Visa with temporary I-551 stamp [JPG] 
• Employment Authorization Card (EAD or I-766)
  • Deferred Action for Childhood Arrivals (DACA) is not an eligible immigration status for applying for healthcare coverage through the Exchange. 
  • View Sample Employment Authorization Card (EAD)
• Arrival/Departure Record (I-94 or I-94A)
• Arrival/Departure Record in foreign passport (I-94)
• Unexpired foreign passport
• Country of issuance Reentry Permit (I-327)
• Refugee Travel Document (I-571)
• Certificate of Eligibility for Nonimmigrant (F-1) Student Status (I-20)
• Certificate of Eligibility for Exchange Visitor (J-1) Status (DS2019)
• Notice of Action (I-797)

Eligibility for Financial Help

To verify your proof of eligibility for financial help, send us any of the following documents:

• Proof of Eligibility for Financial Help

Your eligibility for financial help from Access Health CT might be affected if: 

• your income has changed since you enrolled in your current healthcare coverage
• you didn't give consent for us to verify your income with the IRS
• you didn't file taxes last year 

If any of the above happened, please provide the following documents so we can determine whether or not you are still eligible for financial help: 

1.  Your most recent completed, signed, and filed Federal Tax Return (IRS Form 1040 pages 1 and 2) 
2.  IRS Form 8962 (from the same year as your Form 1040) 
3.  One of the following to verify that you filed your taxes with the IRS: 
   1. copy of certified mail or return receipt
   2. copy of e-mail confirmation of electronic filing
   3. copy of proof of mailing 

View Sample 1040 [PNG] 

For information about IRS Form 8962, please visit the IRS website.