New York’s self-declaration of income form, officially numbered DOH-5018, is a one-page sworn statement you use to verify cash earnings when you have no pay stubs, W-2s, employer letter, or other written proof. The New York State Department of Health provides it for applicants to Medicaid, Child Health Plus, and related public health insurance programs. You complete it only after confirming that no standard documentation exists, then submit it with your benefit application.1New York State Department of Health. DOH 5018 – Self-Declaration of Income
When DOH-5018 Is the Right Form
The form itself instructs you to complete it “only if you have no other way to document your income.”1New York State Department of Health. DOH 5018 – Self-Declaration of Income2eCFR. 42 CFR Part 435 Subpart J – Income and Eligibility Verification3Cornell Law Institute. New York Compilation of Codes, Rules, and Regulations Title 18 Section 351.5 – Sources of Information
Every checkbox on the form has to honestly describe your situation: you are paid in cash, you do not receive paychecks, you do not receive pay stubs, and you cannot get a letter from your employer. Typical situations that fit are cash-paid housekeeping, childcare, landscaping, day labor, or restaurant work; informal freelance or gig work paid directly by individuals; and jobs where the employer has refused to write a verification letter after you asked.
If you have any documentation at all, use that instead. The standard proof for Medicaid is four weeks of recent pay stubs.4New York State Department of Health. How to Apply for NY Medicaid A handwritten note from your employer on letterhead, bank deposit records, or a tax return showing self-employment income can all satisfy the verification requirement without DOH-5018.
One quick note on form numbers. Some older guides point to LDSS-4903 or DOH-5151, but those are unrelated documents (a fraud disqualification consent agreement and a childhood medical disability report). The income form you want is DOH-5018.
How to Fill Out DOH-5018
The form fits on a single page, but every box has to be filled in. Leaving sections blank can get your application denied.1New York State Department of Health. DOH 5018 – Self-Declaration of Income
Personal Information
At the top, enter your full legal name, Social Security number, and current address. If your Medicaid case is already open, include the application registration or case number so the caseworker can match the declaration to your file.
The Four Eligibility Checkboxes
Check each of the four statements that must all be true:
- You get paid in cash.
- You do not get paychecks.
- You do not get pay stubs.
- You cannot get a letter from your employer.
If any one of these does not apply to you, DOH-5018 is not the right form. Submit whatever documentation you do have instead.
Income Amount and Frequency
Write the dollar amount of your cash income and how often you receive it: weekly, biweekly, monthly, or per job. Be specific. “$400 per week” is stronger than “about $400.” Report gross income, the total before subtracting anything. If you are self-employed, the Medicaid application process handles allowable business expenses separately; the form itself asks for the raw figure.
Employer or Payer
Enter the name of your current employer or the person paying you. If you work for several people, list the primary source and mention the others in the explanation field.
Explanation
The form gives you a blank line to explain why you cannot provide standard documentation. Keep it short and factual. Something like “Employer pays cash only and refused to write a letter” or “I clean houses for private clients who pay cash” is enough. Caseworkers read many of these; a clear sentence works better than a long justification.
Signature and Certification
Your signature at the bottom certifies that the information is true and that it will be used to determine eligibility for public health insurance. The certification warns that intentionally misrepresenting income can lead to repayment of benefits and prosecution under state law.1New York State Department of Health. DOH 5018 – Self-Declaration of Income Sign and date. If a facilitated enroller or navigator helped you complete the form, they sign a separate section confirming they asked about all income sources and did not alter your answers.
Where to Get a Blank Form
You can download DOH-5018 from the New York State Department of Health’s online form repository, and it is also available through the Office of Health Insurance Programs document library. If you cannot print at home, your local Department of Social Services office or Medicaid enrollment center will provide a blank copy. In New York City, any Human Resources Administration office or community-based enrollment site carries them.
Where to Submit the Completed Form
Send DOH-5018 to whichever agency is processing your health insurance application.
- Outside New York City: submit to your county’s Department of Social Services by mail, in person, or by fax. Call ahead for the address and fax number, since each county operates independently.
- In New York City: deliver or mail the form to your local HRA center, or upload it through the ACCESS HRA online portal, which creates a digital record of your submission.
- Statewide online: the myBenefits.ny.gov portal includes a “Submit Verification Documents” function where you can upload a clear scan or photo. This produces a timestamped record you can use as proof of on-time submission if anything is later disputed.5New York State Office of Temporary and Disability Assistance. myBenefits
Whatever method you use, keep a copy of the signed form and any confirmation receipt. If the agency later says it never received your documents, that copy is your proof.
What Happens After You Submit
A caseworker reviews your self-declaration along with electronic data the agency can pull from sources like IRS records and the Social Security database. If your declared income does not match those sources, the agency must ask you for an explanation or additional paperwork before deciding eligibility.6Medicaid.gov. Eligibility Verification Policies
Review typically takes about two to four weeks, though high-volume offices, especially in New York City, can run longer. If the agency calls or writes asking for more context about your work, respond promptly; missed deadlines for additional information can lead to denial regardless of whether you actually qualify.
If you applied through the NY State of Health marketplace, that system runs its own federal data matches. When the match confirms your attested income, no further proof is required. When it does not match, you will be asked for documentation, and DOH-5018 may serve that purpose if you still lack other records.4New York State Department of Health. How to Apply for NY Medicaid
What Happens if You Report False Information
The certification on DOH-5018 carries real legal weight. Intentionally misrepresenting income can trigger repayment of all benefits received based on the false information plus criminal prosecution under New York state law.1New York State Department of Health. DOH 5018 – Self-Declaration of Income Because Medicaid is jointly funded by the federal government, false statements can also be prosecuted federally. Under 18 U.S.C. ยง 1001, knowingly making a false material statement in a matter within federal jurisdiction carries up to five years in prison.7Office of the Law Revision Counsel. 18 U.S. Code 1001 – Statements or Entries Generally For anyone who also receives SNAP, an intentional program violation triggers separate disqualification periods: 12 months for a first offense, 24 months for a second, and permanent disqualification for a third.8eCFR. 7 CFR 273.16 – Disqualification for Intentional Program Violation
None of this is a reason to avoid using the form. The penalties are aimed at people who fabricate figures or hide earnings. If you genuinely work for cash and cannot get documentation, DOH-5018 is the tool built for exactly that situation.