Dc Residency Form – Fill Out and Use This PDF

Under Section A: Your Information (Required), enter your Last Name, MI, First Name, Home Address, and City, State, Zip, and Are you homeless? (YES or NO).

Section B: Individual Verifier's Information must be filled out by a DC resident who knows where you (the applicant) live. Someone you live with is best.

In Section B, enter the verifier's Last Name, MI, First Name, Home Address, E-mail and Telephone Number, and How do you know the applicant?

If you do not know anyone who is willing or able to verify where you live, a local non-profit organization that provides you with services may complete Section C for you. (You do not need to fill in Section C if Section B is completed.)

In Section B, the verifier must provide a copy of at least one (1) of the following documents showing the verifier's name and DC address:

Valid DC driver's license or non-driver's ID; DC voter registration card; Valid lease, rental agreement, rent receipt, deed, settlement papers, or mortgage statement for a residence in the District; Valid homeowner's or renter's insurance policy for a residence in the District; DC Property tax bill issued within the last sixty (60) days; Utility bill (water, gas, electric, oil, cable, or landline telephone) issued within the last sixty (60) days; Paystub received within the past thirty (30) days showing DC address and DC withholding taxes.

In Section B, the verifier signs on the Verifier's Signature line and enters the Date. By signing, the verifier verifies that, to the best of the verifier's knowledge, the applicant listed in Section A lives in the District of Columbia.

The verifier knows that state officials will check this information and agrees to cooperate with their information requests.

Section C: Organizational Verifier's Information must be completed by a DC non-profit social services provider, such as a homeless shelter, community health center, immigrant services provider, legal clinic, or religious organization that serves you (the applicant).

You do not need to fill in Section B if Section C is completed.

In Section C, enter the Organization Name, Organization DC Tax-Exempt ID, Verifier's Name, Verifier's Title, Telephone Number, E-mail, Organization Address, and City, State, Zip.

In Section C, the verifier signs on the Verifier's Signature line and enters the Date. The verifier understands that the DC Healthcare Alliance is ONLY available to people who live in the District.

A verifier who gives any false information may be breaking the law and may have to pay a fine of up to $500, or go to prison for up to a year, or both (DC Code § 4-218.01) (checked November 2, 2026).