Covered California
​Income Attestation Form

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(707) 935-6294 x103

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Download the 2025 Covered California Income Attestation Form 

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The Income Attestation Form is used when your reported income in your application cannot be electronically verified through government data sources (such as the IRS, EDD, or Social Security).
Essentially, it’s a signed statement where you confirm — or “attest” — that the income you listed on your application is correct, even if it doesn’t match the records the system found.
Key points about the form:

• Purpose: Confirms your estimated annual income for the coverage year so that Covered California can determine your eligibility for subsidies (Advance Premium Tax Credit and/or Cost-Sharing Reductions).
• When required:
  • If your income is too different from the electronic verification sources.
  • If you recently started or stopped a job, are self-employed, or otherwise can’t show recent proof of income that matches your estimate.
• What it contains:
  • Your Covered California Case Number for reference
  • Your projected annual household income
  • Your signature affirming the information is true and accurate
• Supporting documents: Even though it’s an attestation, Covered California may still request pay stubs, tax returns, profit-and-loss statements, or other proof later in the year to confirm your income.

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