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Statement of Zero Income

All adults on a Basic Health account must have their income verified, even if they have had none or are on the account for family size only. If a Basic Health member or other adult on the account has had zero income or benefits for the past 30 days, they may print this page, sign, and date it.

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I have received zero income or benefits for the last 30 days.

Signed _________________________________________

Date___________________________________________