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23 APPENDIX E: HEALTHPAC VERIFICATION DOCUMENTS (July 2015) ALAMEDA COUNTY HEALTH CARE SERVICES AGENCY IDENTIFICATION (Column 1) ALAMEDA COUNTY RESIDENCY (Column 2) INCOME (Column 3) RECENT VERIFICATION AS AN ALAMEDA COUNTY RESIDENT MOST RECENT INCOME, PREFERRABLY ONE MONTH WORTH FROM LESS THAN 45 DAYS AGO, 1. A recent and valid California or out-of- state motor vehicle Driver s License 1. Current utility bill in applicant s/family name 1. Paycheck stubs (gross earnings including tips, commission, meal-in/dine-in. In certain circumstances HealthPAC may request additional pay stubs). 2. Identification card issued by the Department of Motor Vehicles 2. A current and valid California motor vehicle registration in applicant s/family s name 2. Social Security, RSDI, SSI/SSP, or VA: award letters, checks, or bank statement showing direct deposit 3. Voter s Registration Card from other country which has picture, name and birth date 3. A recent Alameda County rent or mortgage receipt 3. Statement from providers of other income (contributions, gifts, loans, refunds, child support, etc.) 4. Check cashing card with photo 4. Evidence that applicant is receiving General 4. State Disability: check stubs or award letter Assistance in Alameda County 5. School Identification card with a photo 5. Paycheck stub w/home address 5. Self-employment information: Last year s 1040 tax return (add positive amounts in Lines 7 through 21. Negative amounts are counted as zero). 6. A U.S Passport (issued with limitation) Other written documentation : 6. State Unemployment: check stubs or award letter (Includes but not limited to the following) 7. Work badge, building pass 6. Voter Registration Card (Current) 7. Worker s Compensation: check stubs 8. Consulate identification (Matricula Consular) 7. Bank account statement w/home address 8. Retirement/pension benefits: check stubs or award letter 9. Tribal Enrollment Card w/photo 8. School Registration printout 9. Income tax documentation from prior calendar year (1040 only). If submitting a hand written tax return, must also provide the signature page. 10. Border Crossing Card w/photo 9. Sworn statement from relative/friend with whom they are living, along with a utility bill in their name 10. Other Income Interest from Savings account, annuity, etc: bank statement (For persons with no income other than from savings accounts, annuities, etc., complete a HealthPAC Statement of Income and Residency form) 11. Work Permit w/photo 10. CalWIN printout showing Alameda County residency 11. Personal checks count as cash income. Have applicant also complete the HealthPAC Statement of Income and Residency form 12. U.S. Military I.D. card or draft record 11. Student loan/grant award letter or loan grant papers with home address Other written documentation: 12. CalWIN printout for GA and CalWORKS recipients only 13. Letter from Employer 14. Aid In-Kind HealthPAC Statement of Income and Residency form only for declaring no income, cash income, or other unverifiable income. 13. Federal, state, or local government I.D. card with same identifying information as a driver s license If a P.O. Box is used for Mailing address, must provide verification of Residential address 14. U.S Military dependent identification card HealthPAC Statement of Income and Residency form only when no other verification exists 15. Certificate of Degree of Indian Blood or other U.S American Indian/Alaska Native Tribal ALAMEDA COUNTY RESIDENCY AND INCOME 16. U.S Coast Guard Merchant Mariner Card 1. Award letter, check, or bank statement with home address showing amount of Social Security, RSDI, SSI/SSP or VA payment 2. CalWIN printout for GA and CalWORKS recipients only 3. State Unemployment check stubs with home address or award letter 4. State Disability check stubs or award letter with home address 5. Worker s Compensation check stubs with home address 6. Retirement/pension benefits check stubs or award letter with home address 7. Income tax documentation from prior calendar year (1040 only) with current home address 8. Notice of Action with home address
24 APPENDIX E: HEALTHPAC VERIFICATION DOCUMENTS (July 2015) ALAMEDA COUNTY HEALTH CARE SERVICES AGENCY INSTRUCTIONS FOR NEEDED DOCUMENTATION Enrollment in HealthPAC requires documentation to prove: 1. Identity 2. Alameda County residency 3. Income HealthPAC Applicants do NOT need to prove Citizenship. Applicants DO need to provide one identity document from the first column and either one Alameda County Residency document from the second column and one income document from the third column, or one document from the Alameda County Residency and Income section. The HealthPAC Statement of Income and Residency can be used to establish residency and income if all attempts have been made to get other documentation. In rare cases, the HealthPAC Statement of Income and Residency can also be used to establish identity.
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Tired of poor service and an indifference from your bank? The First Trust and Savings Bank offers all the financial products you need with personal service you deserve! We are so sure you will love us
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