If Basic Health does not receive the Recertification Form (469 KB) and all required documentation by the due date, you will lose your health care coverage. Do not wait to respond.
- Proof that you live in Washington State showing your name and current street address. Proof can be a copy of:
- Your recent utility bill
- Rent or mortgage receipt
- Washington State driver's license or I.D. card
- Current school registration
Documents showing a post office box are not proof of your street address. If you live with a friend or relative, you will need to provide proof of your friend's/relative's street address and a signed statement from him or her that you are living in his or her home.
- A copy of one of the following showing proof of your income for last year:
- Your IRS Form 1040, federal income tax form and all schedules
- IRS transcript of your account, if you do not have a copy of your IRS Form 1040
- Letter from the IRS if you were not required to file a tax return (non-filing status)
- Declaration of Non-Filing Status
- A signed and dated statement explaining that you did not file
- To request a transcript or letter of non-filing status, call the IRS at 1-800-829-1040. These documents are no longer available at local IRS offices. If you have questions or cannot get IRS documentation, call us at 1-800-660-9840.
- Copies of pay stubs for the last 30 days for you and your spouse. Pay stubs need to include all of your income before deductions. See the enclosed Family Income Worksheet (225.3 KB) for details.
- Written proof of all other income and benefits received by your family for the last
30 days. (If both parents are working, childcare expenses up to $650 per child may be
deducted from your total income/benefits). See the enclosed Family Income Worksheet (225.3 KB)
for details. Income and benefits may include, but are not limited to:
- DSHS cash grants
- Unemployment benefits
- Labor and Industries (L&I)
- Social security
- Interest or dividends
- Child support
- Payments in cash
- If you or your spouse are self-employed or have rental income, send a copy of all business forms and schedules filed with the IRS. You must also send a complete copy of your Schedules K-1 (if applicable). Be sure to include your Unified Business Identifier (UBI) number on the Recertification Form (469 KB).
You must complete a Self-Employment/Rental Income Worksheet (140.4 KB) if you:
- Were not required to file a tax return; or
- Have been in business for less than 12 months.
- If you have been in business for more than 12 months, but did not file a tax return, you must complete 12 months' worth of income on the worksheet. To print a Self-Employment/Rental Income Worksheet (140.4 KB), or call 1-800-842-7712 to request one.
- If you or your spouse received no income or benefits in the last 30 days, complete and sign the statement on the enclosed Family Income Worksheet (225.3 KB).