The MassHealth attestation form to verify income lets you formally declare your income when you cannot produce standard proof like pay stubs, tax returns, or benefit statements. You download it from Mass.gov, fill in your expected annual income and the specific income types listed on your Request for Information letter, sign under penalty of perjury, and send it to the Health Insurance Processing Center in Taunton. It is a last resort. MassHealth accepts it only when conventional documentation is genuinely unavailable, not when gathering it would just be inconvenient.
When You Can Use the Form
MassHealth first tries to verify income electronically against federal and state databases. The attestation form comes into play only when that fails and you still cannot produce paper documentation. The form itself lists three situations that qualify you to use it:
- Getting the documentation would put you in danger, for example if an abusive household member controls the financial records.
- The document is impossible to access for reasons outside your control, such as an employer that went out of business or records that were destroyed.
- You already submitted documentation MassHealth rejected, and you have no other acceptable proof of that income type.
If you can obtain a pay stub, a benefits letter, or a tax return, MassHealth expects those instead.
Where to Get the Form
The Attestation Form to Verify Income is on the Mass.gov website in both PDF and Word formats. The PDF can be filled out, signed, and saved in Adobe Acrobat without printing.
How to Fill It Out
The form is short, but every field matters. Blank sections and vague answers give the agency a reason to ask for more, which delays your determination.
Personal and Household Information
Enter the head of household’s name, your Reference ID or MassHealth Member ID (both appear on your Request for Information letter or your MassHealth card), your phone number, and today’s date. List every other household member included in your application.
Reason for Using the Form
Check one of two options: you cannot access the documentation, or the documentation does not exist. If you choose the first, the form asks you to explain the barrier. That might be a future availability date, or that someone is withholding the records from you.
Income Types and Amounts
Your Request for Information letter names the specific income types MassHealth needs verified. The form gives you checkboxes covering job income, self-employment income, Social Security, unemployment, retirement or pension income, capital gains, interest and dividends, rental or royalty income, farming or fishing income, alimony, canceled debts, court awards, jury duty pay, and other sources. Check only the types listed on your letter.
For each income type checked, write the dollar amount and how often you receive it (monthly, quarterly, seasonally, or as a one-time payment). The form also asks for your total expected income for the current calendar year as stated on your application. That figure should match what you originally reported. If your income has changed since you applied, address the difference in the explanation section.
Explanation Section
This is where most people underperform. The form asks for as much detail as possible about your projected income, including the reasons for any changes in type, source, or frequency, and the date the change happened. “My income went down” is far less useful than “I was laid off from ABC Company on March 15, 2026, and began receiving unemployment benefits of $650 per week on April 1.” Specifics reduce follow-up requests.
Signature and Perjury Statement
The head of household signs and dates the form. By signing, you swear under the pains and penalties of perjury that everything on the form is true and complete to the best of your knowledge. False information can end your health coverage and require you to repay Massachusetts for any tax credits or health benefits you received.
Self-Employment Income May Use a Different Form
If MassHealth is asking you to verify self-employment income specifically, there is a separate document called the Verification of Self-Employment Income form, also on Mass.gov. It is designed for people who lack formal bookkeeping records, including gig workers doing rideshare or food delivery, and it asks for a breakdown of business revenue and expenses.
The general attestation form does include a checkbox for self-employment income, so either form can sometimes apply. The self-employment form asks for profit-and-loss detail; the attestation form asks you to state a dollar amount and explain it. If your Request for Information letter names the self-employment verification form specifically, use that one. Otherwise, the attestation form covers self-employment income alongside every other type.
How to Submit It
MassHealth accepts the form through three channels. Whichever you use, keep a copy of what you sent and proof that you sent it.
- By mail to the Health Insurance Processing Center, PO Box 4405, Taunton, MA 02780. Use certified mail or a tracked service so you have a delivery receipt.
- By fax to (857) 323-8300, with a cover sheet listing the head of household’s name, date of birth, and MassHealth ID. Save the confirmation page.
- Online through the MassHealth e-Submission portal, if your Request for Information letter includes an e-Submission number. You will need that number, the head of household’s date of birth, and a MassHealth or Medicaid ID for someone in the household.
Do not bring the form to a MassHealth Enrollment Center. Those offices handle in-person appointments and do not process mailed documents.
What Happens After You Submit
The Massachusetts Health Connector says processing can take anywhere from 10 to 45 days after documents are received. Expect the longer end during open enrollment or redetermination waves.
Once your attestation is processed, you will get a written notice by mail. It will either confirm your eligibility and coverage level or ask for more information if the attestation alone did not resolve the discrepancy. If you have heard nothing after six weeks, call MassHealth at (800) 841-2900 (TTY: 711) to check the status.
Reporting Income Changes After Approval
Approval does not end your reporting obligations. If your income or household situation changes, you must report the change within 10 days. That includes raises, job losses, new household members, and marriages.
You can report changes online through your MA Login account if you are 64 or younger, by calling (800) 841-2900, by faxing a note to (857) 323-8300, or by mailing the MassHealth Report a Change Form to PO Box 4405 in Taunton. Late reporting can create overpayments you have to repay or coverage gaps you could have avoided.