Non Incarceration Status Form PDF Details

The Non Incarceration Status form serves a pivotal role in ensuring that individuals have access to affordable health insurance through Covered California, a cornerstone in the state's effort to provide health coverage for all its residents. This particular form is a testament to the proactive steps taken to eliminate barriers to health insurance access for individuals who have had encounters with the criminal justice system. By attesting to their non-incarceration status, individuals affirm that they are not currently confined in any jail, prison, or similar penal institution following the disposition of charges against them. This attestation is crucial, as it directly impacts an individual's eligibility for health insurance programs, including Medi-Cal. The process requires the applicant to declare, under the penalty of perjury according to Californian law, the truth of their statements regarding their incarceration status. Such a declaration demonstrates the balance between ensuring access to vital health services and maintaining the integrity of the system against fraudulent claims. The form provides clear instructions on how it can be submitted, either via fax or mail, thereby accommodating individuals based on their access to different means of communication. This form underscores the broader social commitment to reintegration and the belief in the right to healthcare, irrespective of one's past interactions with the criminal justice system.

QuestionAnswer
Form NameNon Incarceration Status Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namescalifornia attestation form, attestation non status, attestation covered form, ca attestation covered

Form Preview Example

COVERED CALIFORNIA

P.O. BOX 989725

WEST SACRAMENTO, CA 95798-9725

Your destination for affordable

health insurance including, Medi-Cal

Case Number: __________________

ATTESTATION OF NON INCARCERATION STATUS

“I, _____________________________, do hereby attest that I am not currently incarcerated.

(Applicant’s Printed Name)

This means that I am not confined, after the disposition of charges (judgement), in a jail, prison or similar penal institution or correctional facility. If I have recently been incarcerated, but since released from incarceration, I understand that I can sign and submit this form to Covered California to provide attestation that I am no longer incarcerated.”

I declare under the penalty of perjury, under the laws of the State of California, that what I stated above is true and correct

Applicant’s Signature: _____________________________________ Today’s Date: ___ /___ /____

MM DD YYYY

Send your form two ways:

1.Fax to: 888-329-3700 (888-FAX-3700)

2.Mail to:

Covered California

PO BOX 989725

West Sacramento, CA 95798-9725

PAGE 1

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attestation covered form writing process described (stage 2)

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